hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Franklin Medical Center,1/6/2025,2.0.0,Franklin Medical Center,"2106 Loop Rd, Winnsboro, LA 71295",721014937,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|BCBS HMO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS HMO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS HMO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS HMO|COMMERCIAL,standard_charge|BCBS HMO|COMMERCIAL|methodology,additional_payer_notes|BCBS HMO|COMMERCIAL,standard_charge|BCBS PHYSICIAN|COMMERCIAL|negotiated_dollar,standard_charge|BCBS PHYSICIAN|COMMERCIAL|negotiated_percentage,standard_charge|BCBS PHYSICIAN|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS PHYSICIAN|COMMERCIAL,standard_charge|BCBS PHYSICIAN|COMMERCIAL|methodology,additional_payer_notes|BCBS PHYSICIAN|COMMERCIAL,standard_charge|BCBS PPO|COMMERCIAL|negotiated_dollar,standard_charge|BCBS PPO|COMMERCIAL|negotiated_percentage,standard_charge|BCBS PPO|COMMERCIAL|negotiated_algorithm,estimated_amount|BCBS PPO|COMMERCIAL,standard_charge|BCBS PPO|COMMERCIAL|methodology,additional_payer_notes|BCBS PPO|COMMERCIAL,standard_charge|HUMANA MEDICAID|MEDICAID|negotiated_dollar,standard_charge|HUMANA MEDICAID|MEDICAID|negotiated_percentage,standard_charge|HUMANA MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|HUMANA MEDICAID|MEDICAID,standard_charge|HUMANA MEDICAID|MEDICAID|methodology,additional_payer_notes|HUMANA MEDICAID|MEDICAID,standard_charge|MEDICAID|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|MEDICAID,standard_charge|MEDICAID|MEDICAID|methodology,additional_payer_notes|MEDICAID|MEDICAID,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|UHC|COMMERCIAL|negotiated_dollar,standard_charge|UHC|COMMERCIAL|negotiated_percentage,standard_charge|UHC|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC|COMMERCIAL,standard_charge|UHC|COMMERCIAL|methodology,additional_payer_notes|UHC|COMMERCIAL,standard_charge|UHC MEDICAID|MEDICAID|negotiated_dollar,standard_charge|UHC MEDICAID|MEDICAID|negotiated_percentage,standard_charge|UHC MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|UHC MEDICAID|MEDICAID,standard_charge|UHC MEDICAID|MEDICAID|methodology,additional_payer_notes|UHC MEDICAID|MEDICAID,standard_charge|min,standard_charge|max,additional_generic_notes
I.V. DELIVERY MODULE (BLUE),420507,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,28.76,76.5,
sildenafil 20 mg Tab [FMC],2527372,CDM,250,RC,,,OUTPATIENT,1,EA,65.01,39.006,,55.26,85,,44.208,Percent of total billed charges,85% of total billed charges,32.51,50,,26.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.51,50,,26.008,percent of total billed charges,50% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,26,40,,20.8,percent of total billed charges,40% of total billed charges,20.77,55.26,
sildenafil 20 mg Tab [FMC],2527372,CDM,250,RC,,,OUTPATIENT,1,EA,65.01,39.006,,55.26,85,,44.208,Percent of total billed charges,85% of total billed charges,32.51,50,,26.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.51,50,,26.008,percent of total billed charges,50% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,26,40,,20.8,percent of total billed charges,40% of total billed charges,20.77,55.26,
sildenafil 20 mg Tab [FMC],2527372,CDM,250,RC,,,OUTPATIENT,1,EA,65.74,39.444,,55.88,85,,44.704,Percent of total billed charges,85% of total billed charges,32.87,50,,26.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.87,50,,26.296,percent of total billed charges,50% of total billed charges,21,31.95,,16.8,percent of total billed charges,31.95% of total billed charges,21,31.95,,16.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.98,38,,19.984,percent of total billed charges,38% of total billed charges,26.3,40,,21.04,percent of total billed charges,40% of total billed charges,21,55.88,
sildenafil 20 mg Tab [FMC],2527372,CDM,250,RC,,,OUTPATIENT,1,EA,4.53,2.718,,3.85,85,,3.08,Percent of total billed charges,85% of total billed charges,2.27,50,,1.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.27,50,,1.816,percent of total billed charges,50% of total billed charges,1.45,31.95,,1.16,percent of total billed charges,31.95% of total billed charges,1.45,31.95,,1.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.72,38,,1.376,percent of total billed charges,38% of total billed charges,1.81,40,,1.448,percent of total billed charges,40% of total billed charges,1.45,3.85,
sildenafil 20 mg Tab [FMC],2527372,CDM,250,RC,,,OUTPATIENT,1,EA,65.74,39.444,,55.88,85,,44.704,Percent of total billed charges,85% of total billed charges,32.87,50,,26.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.87,50,,26.296,percent of total billed charges,50% of total billed charges,21,31.95,,16.8,percent of total billed charges,31.95% of total billed charges,21,31.95,,16.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.98,38,,19.984,percent of total billed charges,38% of total billed charges,26.3,40,,21.04,percent of total billed charges,40% of total billed charges,21,55.88,
insulin isophane human recombinant 100 units/mL SubQ Inj [FMC],2533214,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,35.21,21.126,,29.93,85,,23.944,Percent of total billed charges,85% of total billed charges,0.76,136.6,,41.608,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,45.08,fee schedule,136.60% of BCBS custom fee schedule,12.38,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,11.25,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.38,38,,10.704,percent of total billed charges,38% of total billed charges,11.25,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,0.76,29.93,
Sodium Chloride 0.45% IV Sol 1000 mL [FMC],2550028,CDM,250,RC,J7050,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.98,136.6,,41.696,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,41.744,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,0.98,30.6,
Sodium Chloride 3% IV Sol 500 mL [FMC],2550069,CDM,250,RC,J7131,HCPCS,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.01,136.6,,41.696,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,38.904,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,28.8,percent of total billed charges,35.15% of total billed charges,23.96,31.95,,28.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,36.064,percent of total billed charges,31.95% of total billed charges,0.01,30.6,
Sodium Chloride 3% IV Sol 500 mL [FMC],2550069,CDM,250,RC,J7131,HCPCS,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.01,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,13.056,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,26.672,percent of total billed charges,35.15% of total billed charges,23.96,31.95,,26.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,33.392,percent of total billed charges,31.95% of total billed charges,0.01,30.6,
ARIPiprazole 10 mg Tab [FMC],2550085,CDM,250,RC,,,OUTPATIENT,1,EA,112.69,67.614,,95.79,85,,76.632,Percent of total billed charges,85% of total billed charges,56.35,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.35,50,,41.608,percent of total billed charges,50% of total billed charges,36,31.95,,24.856,percent of total billed charges,31.95% of total billed charges,36,31.95,,24.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.82,38,,34.256,percent of total billed charges,38% of total billed charges,45.08,40,,31.12,percent of total billed charges,40% of total billed charges,36,95.79,
ARIPiprazole 10 mg Tab [FMC],2550085,CDM,250,RC,,,OUTPATIENT,1,EA,104.35,62.61,,88.7,85,,70.96,Percent of total billed charges,85% of total billed charges,52.18,50,,3.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.18,50,,41.696,percent of total billed charges,50% of total billed charges,33.34,31.95,,8.344,percent of total billed charges,31.95% of total billed charges,33.34,31.95,,8.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.65,38,,31.72,percent of total billed charges,38% of total billed charges,41.74,40,,10.448,percent of total billed charges,40% of total billed charges,33.34,88.7,
ARIPiprazole 10 mg Tab [FMC],2550085,CDM,250,RC,,,OUTPATIENT,1,EA,97.26,58.356,,82.67,85,,66.136,Percent of total billed charges,85% of total billed charges,48.63,50,,3.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48.63,50,,41.696,percent of total billed charges,50% of total billed charges,31.07,31.95,,26.584,percent of total billed charges,31.95% of total billed charges,31.07,31.95,,26.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.96,38,,29.568,percent of total billed charges,38% of total billed charges,38.9,40,,33.288,percent of total billed charges,40% of total billed charges,31.07,82.67,
ARIPiprazole 10 mg Tab [FMC],2550085,CDM,250,RC,,,OUTPATIENT,1,EA,32.64,19.584,,27.74,85,,22.192,Percent of total billed charges,85% of total billed charges,16.32,50,,5.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.32,50,,2.4,percent of total billed charges,50% of total billed charges,10.43,31.95,,26.64,percent of total billed charges,31.95% of total billed charges,10.43,31.95,,26.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.4,38,,9.92,percent of total billed charges,38% of total billed charges,13.06,40,,33.36,percent of total billed charges,40% of total billed charges,10.43,27.74,
ARIPiprazole 10 mg Tab [FMC],2550085,CDM,250,RC,,,OUTPATIENT,1,EA,104.02,62.412,,88.42,85,,70.736,Percent of total billed charges,85% of total billed charges,52.01,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.01,50,,2.4,percent of total billed charges,50% of total billed charges,33.23,31.95,,26.64,percent of total billed charges,31.95% of total billed charges,33.23,31.95,,26.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.53,38,,31.624,percent of total billed charges,38% of total billed charges,41.61,40,,33.36,percent of total billed charges,40% of total billed charges,33.23,88.42,
ARIPiprazole 10 mg Tab [FMC],2550085,CDM,250,RC,,,OUTPATIENT,1,EA,104.24,62.544,,88.6,85,,70.88,Percent of total billed charges,85% of total billed charges,52.12,50,,4.288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.12,50,,3.752,percent of total billed charges,50% of total billed charges,33.3,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,33.3,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.61,38,,31.688,percent of total billed charges,38% of total billed charges,41.7,40,,1.92,percent of total billed charges,40% of total billed charges,33.3,88.6,
ARIPiprazole 10 mg Tab [FMC],2550085,CDM,250,RC,,,OUTPATIENT,1,EA,104.24,62.544,,88.6,85,,70.88,Percent of total billed charges,85% of total billed charges,52.12,50,,4.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.12,50,,3.752,percent of total billed charges,50% of total billed charges,33.3,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,33.3,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.61,38,,31.688,percent of total billed charges,38% of total billed charges,41.7,40,,1.92,percent of total billed charges,40% of total billed charges,33.3,88.6,
acetaminophen 325 mg Supp [FMC],2550200,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,21.712,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,5.632,percent of total billed charges,50% of total billed charges,1.92,31.95,,13.736,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,12.488,percent of total billed charges,40% of total billed charges,1.92,5.1,
acetaminophen 120 mg Supp [FMC],2550218,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,20.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,25.024,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,613.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,22.752,percent of total billed charges,40% of total billed charges,1.92,5.1,
acetylcysteine 20% Sol [FMC],2550234,CDM,250,RC,J7608,HCPCS,OUTPATIENT,30,ML,48.86,29.316,,41.53,85,,33.224,Percent of total billed charges,85% of total billed charges,14.83,136.6,,21.712,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.83,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,17.17,35.15,,7.208,percent of total billed charges,35.15% of total billed charges,958.5,31.95,,805.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.57,38,,14.856,percent of total billed charges,38% of total billed charges,15.61,31.95,,6.552,percent of total billed charges,31.95% of total billed charges,14.83,958.5,
acetylcysteine 20% Sol [FMC],2550234,CDM,250,RC,J7608,HCPCS,OUTPATIENT,30,ML,89,53.4,,75.65,85,,60.52,Percent of total billed charges,85% of total billed charges,14.83,136.6,,21.712,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.83,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,31.28,35.15,,2.392,percent of total billed charges,35.15% of total billed charges,766.8,31.95,,2.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.82,38,,27.056,percent of total billed charges,38% of total billed charges,28.44,31.95,,3,percent of total billed charges,31.95% of total billed charges,14.83,766.8,
acetylcysteine 20% Sol [FMC],2550234,CDM,250,RC,J7608,HCPCS,OUTPATIENT,30,ML,25.62,15.372,,21.78,85,,17.424,Percent of total billed charges,85% of total billed charges,14.83,136.6,,52.64,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.83,136.6,,3.664,fee schedule,136.60% of BCBS custom fee schedule,9.01,35.15,,2.392,percent of total billed charges,35.15% of total billed charges,1006.43,31.95,,2.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.74,38,,7.792,percent of total billed charges,38% of total billed charges,8.19,31.95,,3,percent of total billed charges,31.95% of total billed charges,8.19,1006.43,
acetaZOLAMIDE 250 mg Tab [FMC],2550242,CDM,250,RC,,,OUTPATIENT,1,EA,9.37,5.622,,7.96,85,,6.368,Percent of total billed charges,85% of total billed charges,4.69,50,,15.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.69,50,,4.288,percent of total billed charges,50% of total billed charges,2.99,31.95,,3.6,percent of total billed charges,31.95% of total billed charges,2.99,31.95,,3.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.56,38,,2.848,percent of total billed charges,38% of total billed charges,3.75,40,,4.504,percent of total billed charges,40% of total billed charges,2.99,7.96,
acetaZOLAMIDE 250 mg Tab [FMC],2550242,CDM,250,RC,,,OUTPATIENT,1,EA,9.37,5.622,,7.96,85,,6.368,Percent of total billed charges,85% of total billed charges,4.69,50,,15.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.69,50,,4.272,percent of total billed charges,50% of total billed charges,2.99,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,2.99,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.56,38,,2.848,percent of total billed charges,38% of total billed charges,3.75,40,,1.92,percent of total billed charges,40% of total billed charges,2.99,7.96,
acetaZOLAMIDE 250 mg Tab [FMC],2550242,CDM,250,RC,,,OUTPATIENT,1,EA,14.08,8.448,,11.97,85,,9.576,Percent of total billed charges,85% of total billed charges,7.04,50,,15.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.04,50,,21.712,percent of total billed charges,50% of total billed charges,4.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.35,38,,4.28,percent of total billed charges,38% of total billed charges,5.63,40,,0.96,percent of total billed charges,40% of total billed charges,4.5,11.97,
acetaminophen 650 mg Sup [FMC],2550259,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,137.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,20.672,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq [FMC],2550267,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,138.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,21.712,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.344,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.928,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq [FMC],2550267,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,138.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,21.712,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.744,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.432,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq [FMC],2550267,CDM,250,RC,,,OUTPATIENT,5,ML,9.16,5.496,,7.79,85,,6.232,Percent of total billed charges,85% of total billed charges,4.58,50,,2.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.58,50,,52.64,percent of total billed charges,50% of total billed charges,2.93,31.95,,2.728,percent of total billed charges,31.95% of total billed charges,2.93,31.95,,2.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.48,38,,2.784,percent of total billed charges,38% of total billed charges,3.66,40,,3.416,percent of total billed charges,40% of total billed charges,2.93,7.79,
acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq [FMC],2550267,CDM,250,RC,,,OUTPATIENT,5,ML,10.72,6.432,,9.11,85,,7.288,Percent of total billed charges,85% of total billed charges,5.36,50,,2.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.36,50,,15.104,percent of total billed charges,50% of total billed charges,3.43,31.95,,9651.176,percent of total billed charges,31.95% of total billed charges,3.43,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.07,38,,3.256,percent of total billed charges,38% of total billed charges,4.29,40,,8772.552,percent of total billed charges,40% of total billed charges,3.43,9.11,
acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq [FMC],2550267,CDM,250,RC,,,OUTPATIENT,5,ML,10.68,6.408,,9.08,85,,7.264,Percent of total billed charges,85% of total billed charges,5.34,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.34,50,,15.096,percent of total billed charges,50% of total billed charges,3.41,31.95,,13.872,percent of total billed charges,31.95% of total billed charges,3.41,31.95,,13.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.06,38,,3.248,percent of total billed charges,38% of total billed charges,4.27,40,,17.368,percent of total billed charges,40% of total billed charges,3.41,9.08,
alteplase 100 mg IV Inj [FMC],2550317,CDM,250,RC,J2997,HCPCS,OUTPATIENT,1,EA,34321.4,20592.84,,29173.19,85,,23338.552,Percent of total billed charges,85% of total billed charges,133.98,136.6,,9.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,133.98,136.6,,15.096,fee schedule,136.60% of BCBS custom fee schedule,12063.97,35.15,,13.208,percent of total billed charges,35.15% of total billed charges,23.96,31.95,,13.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13042.13,38,,10433.704,percent of total billed charges,38% of total billed charges,10965.69,31.95,,16.536,percent of total billed charges,31.95% of total billed charges,23.96,29173.19,
charcoal-sorbitol 25 gm Susp [FMC],2550325,CDM,250,RC,,,OUTPATIENT,120,ML,54.28,32.568,,46.14,85,,36.912,Percent of total billed charges,85% of total billed charges,27.14,50,,16.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.14,50,,15.096,percent of total billed charges,50% of total billed charges,17.34,31.95,,13.872,percent of total billed charges,31.95% of total billed charges,17.34,31.95,,13.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.63,38,,16.504,percent of total billed charges,38% of total billed charges,21.71,40,,17.368,percent of total billed charges,40% of total billed charges,17.34,46.14,
charcoal-sorbitol 25 gm Susp [FMC],2550325,CDM,250,RC,,,OUTPATIENT,120,ML,51.68,31.008,,43.93,85,,35.144,Percent of total billed charges,85% of total billed charges,25.84,50,,10.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.84,50,,137.152,percent of total billed charges,50% of total billed charges,16.51,31.95,,13.872,percent of total billed charges,31.95% of total billed charges,16.51,31.95,,13.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.64,38,,15.712,percent of total billed charges,38% of total billed charges,20.67,40,,17.368,percent of total billed charges,40% of total billed charges,16.51,43.93,
charcoal-sorbitol 25 gm Susp [FMC],2550325,CDM,250,RC,,,OUTPATIENT,120,ML,54.28,32.568,,46.14,85,,36.912,Percent of total billed charges,85% of total billed charges,27.14,50,,10.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.14,50,,138.936,percent of total billed charges,50% of total billed charges,17.34,31.95,,33.632,percent of total billed charges,31.95% of total billed charges,17.34,31.95,,33.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.63,38,,16.504,percent of total billed charges,38% of total billed charges,21.71,40,,42.112,percent of total billed charges,40% of total billed charges,17.34,46.14,
charcoal-sorbitol 25 gm Susp [FMC],2550325,CDM,250,RC,,,OUTPATIENT,120,ML,54.28,32.568,,46.14,85,,36.912,Percent of total billed charges,85% of total billed charges,27.14,50,,35.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.14,50,,138.936,percent of total billed charges,50% of total billed charges,17.34,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,17.34,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.63,38,,16.504,percent of total billed charges,38% of total billed charges,21.71,40,,12.08,percent of total billed charges,40% of total billed charges,17.34,46.14,
charcoal 50 g Susp [FMC],2550366,CDM,250,RC,,,OUTPATIENT,240,ML,131.59,78.954,,111.85,85,,89.48,Percent of total billed charges,85% of total billed charges,65.8,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,65.8,50,,2.816,percent of total billed charges,50% of total billed charges,42.04,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,42.04,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50,38,,40,percent of total billed charges,38% of total billed charges,52.64,40,,12.08,percent of total billed charges,40% of total billed charges,42.04,111.85,
pioglitazone 45 mg Tab [FMC],2550416,CDM,250,RC,,,OUTPATIENT,1,EA,37.76,22.656,,32.1,85,,25.68,Percent of total billed charges,85% of total billed charges,18.88,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.88,50,,2.568,percent of total billed charges,50% of total billed charges,12.06,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,12.06,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.35,38,,11.48,percent of total billed charges,38% of total billed charges,15.1,40,,12.08,percent of total billed charges,40% of total billed charges,12.06,32.1,
pioglitazone 45 mg Tab [FMC],2550416,CDM,250,RC,,,OUTPATIENT,1,EA,37.74,22.644,,32.08,85,,25.664,Percent of total billed charges,85% of total billed charges,18.87,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.87,50,,1.2,percent of total billed charges,50% of total billed charges,12.06,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,12.06,31.95,,9.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.34,38,,11.472,percent of total billed charges,38% of total billed charges,15.1,40,,12.08,percent of total billed charges,40% of total billed charges,12.06,32.08,
pioglitazone 45 mg Tab [FMC],2550416,CDM,250,RC,,,OUTPATIENT,1,EA,37.74,22.644,,32.08,85,,25.664,Percent of total billed charges,85% of total billed charges,18.87,50,,1.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.87,50,,9.008,percent of total billed charges,50% of total billed charges,12.06,31.95,,87.64,percent of total billed charges,31.95% of total billed charges,12.06,31.95,,87.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.34,38,,11.472,percent of total billed charges,38% of total billed charges,15.1,40,,109.72,percent of total billed charges,40% of total billed charges,12.06,32.08,
pioglitazone 45 mg Tab [FMC],2550416,CDM,250,RC,,,OUTPATIENT,1,EA,37.74,22.644,,32.08,85,,25.664,Percent of total billed charges,85% of total billed charges,18.87,50,,98.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.87,50,,16.384,percent of total billed charges,50% of total billed charges,12.06,31.95,,88.776,percent of total billed charges,31.95% of total billed charges,12.06,31.95,,88.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.34,38,,11.472,percent of total billed charges,38% of total billed charges,15.1,40,,111.144,percent of total billed charges,40% of total billed charges,12.06,32.08,
ketorolac Ophth 0.5% Sol [FMC],2550432,CDM,250,RC,,,OUTPATIENT,5,EA,342.88,205.728,,291.45,85,,233.16,Percent of total billed charges,85% of total billed charges,171.44,50,,201.712,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,171.44,50,,10.944,percent of total billed charges,50% of total billed charges,109.55,31.95,,88.776,percent of total billed charges,31.95% of total billed charges,109.55,31.95,,88.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,130.29,38,,104.232,percent of total billed charges,38% of total billed charges,137.15,40,,111.144,percent of total billed charges,40% of total billed charges,109.55,291.45,
ketorolac Ophth 0.5% Sol [FMC],2550432,CDM,250,RC,,,OUTPATIENT,5,EA,347.33,208.398,,295.23,85,,236.184,Percent of total billed charges,85% of total billed charges,173.67,50,,249.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,173.67,50,,10.864,percent of total billed charges,50% of total billed charges,110.97,31.95,,1.8,percent of total billed charges,31.95% of total billed charges,110.97,31.95,,1.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.99,38,,105.592,percent of total billed charges,38% of total billed charges,138.93,40,,2.256,percent of total billed charges,40% of total billed charges,110.97,295.23,
ketorolac ophthalmic 0.5% Sol [FMC],2550432,CDM,250,RC,,,OUTPATIENT,5,EA,347.33,208.398,,295.23,85,,236.184,Percent of total billed charges,85% of total billed charges,173.67,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,173.67,50,,35.44,percent of total billed charges,50% of total billed charges,110.97,31.95,,1.64,percent of total billed charges,31.95% of total billed charges,110.97,31.95,,1.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.99,38,,105.592,percent of total billed charges,38% of total billed charges,138.93,40,,2.056,percent of total billed charges,40% of total billed charges,110.97,295.23,
acyclovir 400 mg Tab [FMC],2550473,CDM,250,RC,,,OUTPATIENT,1,EA,7.04,4.224,,5.98,85,,4.784,Percent of total billed charges,85% of total billed charges,3.52,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.52,50,,1.2,percent of total billed charges,50% of total billed charges,2.25,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.25,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.68,38,,2.144,percent of total billed charges,38% of total billed charges,2.82,40,,0.96,percent of total billed charges,40% of total billed charges,2.25,5.98,
acyclovir 400 mg Tab [FMC],2550473,CDM,250,RC,,,OUTPATIENT,1,EA,6.42,3.852,,5.46,85,,4.368,Percent of total billed charges,85% of total billed charges,3.21,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.21,50,,1.2,percent of total billed charges,50% of total billed charges,2.05,31.95,,5.752,percent of total billed charges,31.95% of total billed charges,2.05,31.95,,5.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.44,38,,1.952,percent of total billed charges,38% of total billed charges,2.57,40,,7.2,percent of total billed charges,40% of total billed charges,2.05,5.46,
adenosine 3 mg/mL IV Sol [FMC],2550531,CDM,250,RC,J0153,HCPCS,OUTPATIENT,2,ML,24.17,14.502,,20.54,85,,16.432,Percent of total billed charges,85% of total billed charges,0.81,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.81,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.5,35.15,,10.464,fee schedule,35.15% of LA custom fee schedule,7.72,31.95,,10.464,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.18,38,,7.344,percent of total billed charges,38% of total billed charges,7.72,31.95,,13.104,Fee Schedule,31.95% of LA custom fee schedule,0.81,20.54,
adenosine 3 mg/mL IV Sol [FMC],2550531,CDM,250,RC,J0153,HCPCS,OUTPATIENT,2,ML,24.38,14.628,,20.72,85,,16.576,Percent of total billed charges,85% of total billed charges,0.81,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.81,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.57,35.15,,6.992,fee schedule,35.15% of LA custom fee schedule,7.79,31.95,,6.992,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.26,38,,7.408,percent of total billed charges,38% of total billed charges,7.79,31.95,,8.752,Fee Schedule,31.95% of LA custom fee schedule,0.81,20.72,
adenosine 3 mg/mL IV Sol [FMC],2550531,CDM,250,RC,J0153,HCPCS,OUTPATIENT,2,ML,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,0.81,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.81,136.6,,1.224,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,6.936,fee schedule,35.15% of LA custom fee schedule,7.48,31.95,,6.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,8.688,Fee Schedule,31.95% of LA custom fee schedule,0.81,19.89,
ibuprofen 200 mg Tab [FMC],2550622,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,22.648,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,22.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,28.352,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin-dipyridamole 25 mg-200 mg ER [FMC],2550671,CDM,250,RC,,,OUTPATIENT,1,EA,22.51,13.506,,19.13,85,,15.304,Percent of total billed charges,85% of total billed charges,11.26,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.26,50,,1.224,percent of total billed charges,50% of total billed charges,7.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.55,38,,6.84,percent of total billed charges,38% of total billed charges,9,40,,0.96,percent of total billed charges,40% of total billed charges,7.19,19.13,
aspirin-dipyridamole 25 mg-200 mg ER [FMC],2550671,CDM,250,RC,,,OUTPATIENT,1,EA,40.95,24.57,,34.81,85,,27.848,Percent of total billed charges,85% of total billed charges,20.48,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.48,50,,98.28,percent of total billed charges,50% of total billed charges,13.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.56,38,,12.448,percent of total billed charges,38% of total billed charges,16.38,40,,0.96,percent of total billed charges,40% of total billed charges,13.08,34.81,
aspirin-dipyridamole 25 mg-200 mg ER [FMC],2550671,CDM,250,RC,,,OUTPATIENT,1,EA,27.35,16.41,,23.25,85,,18.6,Percent of total billed charges,85% of total billed charges,13.68,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.68,50,,201.712,percent of total billed charges,50% of total billed charges,8.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,8.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.39,38,,8.312,percent of total billed charges,38% of total billed charges,10.94,40,,0.96,percent of total billed charges,40% of total billed charges,8.74,23.25,
aspirin-dipyridamole 25 mg-200 mg ER [FMC],2550671,CDM,250,RC,,,OUTPATIENT,1,EA,27.15,16.29,,23.08,85,,18.464,Percent of total billed charges,85% of total billed charges,13.58,50,,2.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.58,50,,249.184,percent of total billed charges,50% of total billed charges,8.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,8.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.32,38,,8.256,percent of total billed charges,38% of total billed charges,10.86,40,,0.96,percent of total billed charges,40% of total billed charges,8.67,23.08,
albuterol CFC free 90 mcg/inh Inh Aer [FMC],2550747,CDM,250,RC,,,OUTPATIENT,8,UN,88.6,53.16,,75.31,85,,60.248,Percent of total billed charges,85% of total billed charges,44.3,50,,2.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.3,50,,1.6,percent of total billed charges,50% of total billed charges,28.31,31.95,,0.784,percent of total billed charges,31.95% of total billed charges,28.31,31.95,,0.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.67,38,,26.936,percent of total billed charges,38% of total billed charges,35.44,40,,0.976,percent of total billed charges,40% of total billed charges,28.31,75.31,
allopurinol 100 mg Tab [FMC],2550812,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
allopurinol 100 mg Tab [FMC],2550812,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.784,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.976,percent of total billed charges,40% of total billed charges,0.96,2.55,
allopurinol 100 mg Tab [FMC],2550812,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,62.8,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,62.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,78.624,percent of total billed charges,40% of total billed charges,0.96,2.55,
allopurinol 100 mg Tab [FMC],2550812,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,128.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,128.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,161.368,percent of total billed charges,40% of total billed charges,0.96,2.55,
allopurinol 300 mg Tab [FMC],2550820,CDM,250,RC,,,OUTPATIENT,1,EA,3.06,1.836,,2.6,85,,2.08,Percent of total billed charges,85% of total billed charges,1.53,50,,2.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.53,50,,1.6,percent of total billed charges,50% of total billed charges,0.98,31.95,,159.232,percent of total billed charges,31.95% of total billed charges,0.98,31.95,,159.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.16,38,,0.928,percent of total billed charges,38% of total billed charges,1.22,40,,199.344,percent of total billed charges,40% of total billed charges,0.98,2.6,
allopurinol 300 mg Tab [FMC],2550820,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
allopurinol 300 mg Tab [FMC],2550820,CDM,250,RC,,,OUTPATIENT,1,EA,3.06,1.836,,2.6,85,,2.08,Percent of total billed charges,85% of total billed charges,1.53,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.53,50,,1.6,percent of total billed charges,50% of total billed charges,0.98,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.98,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.16,38,,0.928,percent of total billed charges,38% of total billed charges,1.22,40,,1.28,percent of total billed charges,40% of total billed charges,0.98,2.6,
brimonidine Ophth 0.15% Soln 5 mL [FMC],2550853,CDM,250,RC,,,OUTPATIENT,5,EA,245.7,147.42,,208.85,85,,167.08,Percent of total billed charges,85% of total billed charges,122.85,50,,1.584,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,122.85,50,,1.6,percent of total billed charges,50% of total billed charges,78.5,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,78.5,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,93.37,38,,74.696,percent of total billed charges,38% of total billed charges,98.28,40,,1.28,percent of total billed charges,40% of total billed charges,78.5,208.85,
brimonidine Ophth 0.15% Soln 5 mL [FMC],2550853,CDM,250,RC,,,OUTPATIENT,5,EA,504.27,302.562,,428.63,85,,342.904,Percent of total billed charges,85% of total billed charges,252.14,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,252.14,50,,1.6,percent of total billed charges,50% of total billed charges,161.11,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,161.11,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,191.62,38,,153.296,percent of total billed charges,38% of total billed charges,201.71,40,,1.28,percent of total billed charges,40% of total billed charges,161.11,428.63,
brimonidine Ophth 0.15% Soln 5 mL [FMC],2550853,CDM,250,RC,,,OUTPATIENT,5,EA,622.96,373.776,,529.52,85,,423.616,Percent of total billed charges,85% of total billed charges,311.48,50,,4.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,311.48,50,,2.352,percent of total billed charges,50% of total billed charges,199.04,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,199.04,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,236.72,38,,189.376,percent of total billed charges,38% of total billed charges,249.18,40,,1.28,percent of total billed charges,40% of total billed charges,199.04,529.52,
ALPRAZolam 0.25 mg Tab [FMC],2550887,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,9.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.52,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 0.25 mg Tab [FMC],2550887,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 0.25 mg Tab [FMC],2550887,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.352,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 0.25 mg Tab [FMC],2550887,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.528,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 0.5 mg Tab [FMC],2550895,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 0.5 mg Tab [FMC],2550895,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.192,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.504,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.88,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 0.5 mg Tab [FMC],2550895,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.192,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.608,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,2.016,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 0.5 mg Tab [FMC],2550895,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 1 mg Tab [FMC],2550903,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.584,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.504,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.88,percent of total billed charges,40% of total billed charges,1.28,3.4,
ALPRAZolam 1 mg Tab [FMC],2550903,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,2.896,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.624,percent of total billed charges,40% of total billed charges,1.28,3.4,
ramipril 2.5 mg Cap [FMC],2550945,CDM,250,RC,,,OUTPATIENT,1,EA,5.87,3.522,,4.99,85,,3.992,Percent of total billed charges,85% of total billed charges,2.94,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.94,50,,4.28,percent of total billed charges,50% of total billed charges,1.88,31.95,,1.784,percent of total billed charges,31.95% of total billed charges,1.88,31.95,,1.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.23,38,,1.784,percent of total billed charges,38% of total billed charges,2.35,40,,2.24,percent of total billed charges,40% of total billed charges,1.88,4.99,
ramipril 2.5 mg Cap [FMC],2550945,CDM,250,RC,,,OUTPATIENT,1,EA,6.3,3.78,,5.36,85,,4.288,Percent of total billed charges,85% of total billed charges,3.15,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.15,50,,9.648,percent of total billed charges,50% of total billed charges,2.01,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,2.01,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.39,38,,1.912,percent of total billed charges,38% of total billed charges,2.52,40,,1.752,percent of total billed charges,40% of total billed charges,2.01,5.36,
ramipril 2.5 mg Cap [FMC],2550945,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.752,percent of total billed charges,40% of total billed charges,0.96,2.55,
ramipril 2.5 mg Cap [FMC],2550945,CDM,250,RC,,,OUTPATIENT,1,EA,5.87,3.522,,4.99,85,,3.992,Percent of total billed charges,85% of total billed charges,2.94,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.94,50,,1.2,percent of total billed charges,50% of total billed charges,1.88,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.88,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.23,38,,1.784,percent of total billed charges,38% of total billed charges,2.35,40,,1.28,percent of total billed charges,40% of total billed charges,1.88,4.99,
amantadine 100 mg Cap [FMC],2550986,CDM,250,RC,,,OUTPATIENT,1,EA,11.32,6.792,,9.62,85,,7.696,Percent of total billed charges,85% of total billed charges,5.66,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.66,50,,1.2,percent of total billed charges,50% of total billed charges,3.62,31.95,,1.016,percent of total billed charges,31.95% of total billed charges,3.62,31.95,,1.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.3,38,,3.44,percent of total billed charges,38% of total billed charges,4.53,40,,1.264,percent of total billed charges,40% of total billed charges,3.62,9.62,
amantadine 100 mg Cap [FMC],2550986,CDM,250,RC,,,OUTPATIENT,1,EA,6.99,4.194,,5.94,85,,4.752,Percent of total billed charges,85% of total billed charges,3.5,50,,1.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,1.2,percent of total billed charges,50% of total billed charges,2.23,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,2.23,31.95,,760.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,2.128,percent of total billed charges,38% of total billed charges,2.8,40,,3.064,percent of total billed charges,40% of total billed charges,2.23,5.94,
amantadine 100 mg Cap [FMC],2550986,CDM,250,RC,,,OUTPATIENT,1,EA,5.47,3.282,,4.65,85,,3.72,Percent of total billed charges,85% of total billed charges,2.74,50,,1.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.74,50,,1.2,percent of total billed charges,50% of total billed charges,1.75,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.08,38,,1.664,percent of total billed charges,38% of total billed charges,2.19,40,,0.96,percent of total billed charges,40% of total billed charges,1.75,4.65,
amantadine 100 mg Cap [FMC],2550986,CDM,250,RC,,,OUTPATIENT,1,EA,5.47,3.282,,4.65,85,,3.72,Percent of total billed charges,85% of total billed charges,2.74,50,,1.456,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.74,50,,1.2,percent of total billed charges,50% of total billed charges,1.75,31.95,,2.736,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,2.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.08,38,,1.664,percent of total billed charges,38% of total billed charges,2.19,40,,3.424,percent of total billed charges,40% of total billed charges,1.75,4.65,
glimepiride 4 mg Tab [FMC],2551018,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.456,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,6.168,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,6.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,7.72,percent of total billed charges,40% of total billed charges,1.28,3.4,
glimepiride 4 mg Tab [FMC],2551018,CDM,250,RC,,,OUTPATIENT,1,EA,3.96,2.376,,3.37,85,,2.696,Percent of total billed charges,85% of total billed charges,1.98,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.98,50,,1.2,percent of total billed charges,50% of total billed charges,1.27,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.27,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.5,38,,1.2,percent of total billed charges,38% of total billed charges,1.58,40,,0.96,percent of total billed charges,40% of total billed charges,1.27,3.37,
amikacin 250 mg/mL IV 2ml Sol [FMC],2551075,CDM,250,RC,J0278,HCPCS,OUTPATIENT,1,ML,23.9,14.34,,20.32,85,,16.256,Percent of total billed charges,85% of total billed charges,1.41,136.6,,1.328,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.41,136.6,,1.376,fee schedule,136.60% of BCBS custom fee schedule,8.4,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,7.64,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.08,38,,7.264,percent of total billed charges,38% of total billed charges,7.64,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1.41,20.32,
amikacin 250 mg/mL IV 2ml Sol [FMC],2551075,CDM,250,RC,J0278,HCPCS,OUTPATIENT,1,ML,15.11,9.066,,12.84,85,,10.272,Percent of total billed charges,85% of total billed charges,1.41,136.6,,113.528,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.41,136.6,,1.656,fee schedule,136.60% of BCBS custom fee schedule,5.31,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,4.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.74,38,,4.592,percent of total billed charges,38% of total billed charges,4.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1.41,12.84,
amikacin 250 mg/mL IV 2ml Sol [FMC],2551075,CDM,250,RC,J0278,HCPCS,OUTPATIENT,1,ML,23.9,14.34,,20.32,85,,16.256,Percent of total billed charges,85% of total billed charges,1.41,136.6,,113.528,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.41,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.4,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,7.64,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.08,38,,7.264,percent of total billed charges,38% of total billed charges,7.64,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1.41,20.32,
aminophylline 25 mg/mL IV Sol [FMC],2551109,CDM,250,RC,J0280,HCPCS,OUTPATIENT,20,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,15.91,136.6,,117,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,15.91,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,950.51,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,3.83,950.51,
amiodarone 200 mg Tab [FMC],2551125,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,108.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
amiodarone 200 mg Tab [FMC],2551125,CDM,250,RC,,,OUTPATIENT,1,EA,10.69,6.414,,9.09,85,,7.272,Percent of total billed charges,85% of total billed charges,5.35,50,,17.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.35,50,,1.2,percent of total billed charges,50% of total billed charges,3.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.06,38,,3.248,percent of total billed charges,38% of total billed charges,4.28,40,,0.96,percent of total billed charges,40% of total billed charges,3.42,9.09,
amiodarone 200 mg Tab [FMC],2551125,CDM,250,RC,,,OUTPATIENT,1,EA,24.12,14.472,,20.5,85,,16.4,Percent of total billed charges,85% of total billed charges,12.06,50,,2.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.06,50,,1.2,percent of total billed charges,50% of total billed charges,7.71,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.71,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.17,38,,7.336,percent of total billed charges,38% of total billed charges,9.65,40,,0.96,percent of total billed charges,40% of total billed charges,7.71,20.5,
amiodarone 200 mg Tab [FMC],2551125,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.096,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 10 mg Tab [FMC],2551141,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.056,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.32,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 10 mg Tab [FMC],2551141,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 10 mg Tab [FMC],2551141,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.624,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 25 mg Tab [FMC],2551166,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.44,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 25 mg Tab [FMC],2551166,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.456,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 25 mg Tab [FMC],2551166,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.456,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 50 mg Tab [FMC],2551174,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
amoxicillin-clavulanate 875 mg-125 mg Tab [FMC],2551174,CDM,250,RC,,,OUTPATIENT,1,EA,3.43,2.058,,2.92,85,,2.336,Percent of total billed charges,85% of total billed charges,1.72,50,,13.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.72,50,,1.328,percent of total billed charges,50% of total billed charges,1.1,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.1,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.3,38,,1.04,percent of total billed charges,38% of total billed charges,1.37,40,,0.96,percent of total billed charges,40% of total billed charges,1.1,2.92,
amitriptyline 50 mg Tab [FMC],2551174,CDM,250,RC,,,OUTPATIENT,1,EA,4.13,2.478,,3.51,85,,2.808,Percent of total billed charges,85% of total billed charges,2.07,50,,13.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.07,50,,113.528,percent of total billed charges,50% of total billed charges,1.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.57,38,,1.256,percent of total billed charges,38% of total billed charges,1.65,40,,0.96,percent of total billed charges,40% of total billed charges,1.32,3.51,
amitriptyline 50 mg Tab [FMC],2551174,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,13.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,113.528,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.296,percent of total billed charges,40% of total billed charges,0.96,2.55,
amitriptyline 50 mg Tab [FMC],2551174,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,136.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,117,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.152,percent of total billed charges,40% of total billed charges,0.96,2.55,
amoxicillin 250 mg Cap [FMC],2551240,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,108.112,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.16,percent of total billed charges,40% of total billed charges,0.96,2.55,
amoxicillin 250 mg Cap [FMC],2551240,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.296,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.168,percent of total billed charges,40% of total billed charges,0.96,2.55,
amoxicillin 250 mg/5 mL REC [FMC],2551265,CDM,250,RC,,,OUTPATIENT,1,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.696,percent of total billed charges,50% of total billed charges,0.96,31.95,,21.248,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,760.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,19.312,percent of total billed charges,40% of total billed charges,0.96,2.55,
amoxicillin 250 mg/5 mL REC [FMC],2551265,CDM,250,RC,,,OUTPATIENT,1,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.232,percent of total billed charges,50% of total billed charges,0.96,31.95,,21.032,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,760.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,19.12,percent of total billed charges,40% of total billed charges,0.96,2.55,
amoxicillin 250 mg/5 mL REC [FMC],2551265,CDM,250,RC,,,OUTPATIENT,1,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,21.872,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,21.912,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,19.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
amoxicillin 250 mg/5 mL REC [FMC],2551265,CDM,250,RC,,,OUTPATIENT,1,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,75.896,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.424,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
ampicillin 1000 mg Inj [FMC],2551372,CDM,250,RC,J0290,HCPCS,OUTPATIENT,1,EA,26.67,16.002,,22.67,85,,18.136,Percent of total billed charges,85% of total billed charges,1.43,136.6,,72.856,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.43,136.6,,7.568,fee schedule,136.60% of BCBS custom fee schedule,9.37,35.15,,0.848,fee schedule,35.15% of LA custom fee schedule,8.52,31.95,,0.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.13,38,,8.104,percent of total billed charges,38% of total billed charges,8.52,31.95,,1.064,Fee Schedule,31.95% of LA custom fee schedule,1.43,22.67,
ampicillin 1000 mg Inj [FMC],2551372,CDM,250,RC,J0290,HCPCS,OUTPATIENT,1,EA,23.01,13.806,,19.56,85,,15.648,Percent of total billed charges,85% of total billed charges,1.43,136.6,,155.544,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.43,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,8.09,35.15,,72.544,fee schedule,35.15% of LA custom fee schedule,7.35,31.95,,72.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.74,38,,6.992,percent of total billed charges,38% of total billed charges,7.35,31.95,,90.824,Fee Schedule,31.95% of LA custom fee schedule,1.43,19.56,
ampicillin 1000 mg Inj [FMC]`,2551372,CDM,250,RC,J0290,HCPCS,OUTPATIENT,1,EA,28.14,16.884,,23.92,85,,19.136,Percent of total billed charges,85% of total billed charges,1.43,136.6,,155.544,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.43,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,9.89,35.15,,72.544,fee schedule,35.15% of LA custom fee schedule,8.99,31.95,,72.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.69,38,,8.552,percent of total billed charges,38% of total billed charges,8.99,31.95,,90.824,Fee Schedule,31.95% of LA custom fee schedule,1.43,23.92,
ampicillin 1000 mg Inj [FMC],2551372,CDM,250,RC,J0290,HCPCS,OUTPATIENT,1,EA,28.06,16.836,,23.85,85,,19.08,Percent of total billed charges,85% of total billed charges,1.43,136.6,,141.536,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.43,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,9.86,35.15,,74.76,fee schedule,35.15% of LA custom fee schedule,8.97,31.95,,74.76,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.66,38,,8.528,percent of total billed charges,38% of total billed charges,8.97,31.95,,93.6,Fee Schedule,31.95% of LA custom fee schedule,1.43,23.85,
brompheniramine/dextromethorphan/PSE 2 mg-10 mg-30 mg/5 mL Oral Syrup 118 mL [FMC],2551380,CDM,250,RC,,,OUTPATIENT,5,ML,4.05,2.43,,3.44,85,,2.752,Percent of total billed charges,85% of total billed charges,2.03,50,,84.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.03,50,,1.2,percent of total billed charges,50% of total billed charges,1.29,31.95,,69.08,percent of total billed charges,31.95% of total billed charges,1.29,31.95,,69.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.54,38,,1.232,percent of total billed charges,38% of total billed charges,1.62,40,,86.488,percent of total billed charges,40% of total billed charges,1.29,3.44,
brompheniramine/dextromethorphan/PSE 2 mg-10 mg-30 mg/5 mL Oral Syrup 118 mL [FMC],2551380,CDM,250,RC,,,OUTPATIENT,5,ML,3.6,2.16,,3.06,85,,2.448,Percent of total billed charges,85% of total billed charges,1.8,50,,84.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.8,50,,1.2,percent of total billed charges,50% of total billed charges,1.15,31.95,,11.056,percent of total billed charges,31.95% of total billed charges,1.15,31.95,,11.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.37,38,,1.096,percent of total billed charges,38% of total billed charges,1.44,40,,13.84,percent of total billed charges,40% of total billed charges,1.15,3.06,
brompheniramine/dextromethorphan/PSE 2 mg-10 mg-30 mg/5 mL Oral Syrup 118 mL [FMC],2551380,CDM,250,RC,,,OUTPATIENT,5,ML,3.63,2.178,,3.09,85,,2.472,Percent of total billed charges,85% of total billed charges,1.82,50,,84.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.82,50,,1.2,percent of total billed charges,50% of total billed charges,1.16,31.95,,1.72,percent of total billed charges,31.95% of total billed charges,1.16,31.95,,1.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.38,38,,1.104,percent of total billed charges,38% of total billed charges,1.45,40,,2.152,percent of total billed charges,40% of total billed charges,1.16,3.09,
brompheniramine/dextromethorphan/PSE 2 mg-10 mg-30 mg/5 mL Oral Syrup 118 mL [FMC],2551380,CDM,250,RC,,,OUTPATIENT,5,ML,3.64,2.184,,3.09,85,,2.472,Percent of total billed charges,85% of total billed charges,1.82,50,,84.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.82,50,,1.2,percent of total billed charges,50% of total billed charges,1.16,31.95,,4.616,percent of total billed charges,31.95% of total billed charges,1.16,31.95,,4.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.38,38,,1.104,percent of total billed charges,38% of total billed charges,1.46,40,,5.784,percent of total billed charges,40% of total billed charges,1.16,3.09,
succinylcholine 20 mg/mL Inj Sol [FMC],2551406,CDM,250,RC,J0330,HCPCS,OUTPATIENT,10,ML,75.55,45.33,,64.22,85,,51.376,Percent of total billed charges,85% of total billed charges,1.38,136.6,,4.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.38,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,26.56,35.15,,1.536,percent of total billed charges,35.15% of total billed charges,950.51,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.71,38,,22.968,percent of total billed charges,38% of total billed charges,24.14,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,1.38,950.51,
succinylcholine 20 mg/mL Inj Sol [FMC],2551406,CDM,250,RC,J0330,HCPCS,OUTPATIENT,10,ML,74.8,44.88,,63.58,85,,50.864,Percent of total billed charges,85% of total billed charges,1.38,136.6,,2.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.38,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,26.29,35.15,,4.104,percent of total billed charges,35.15% of total billed charges,950.51,31.95,,4.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.42,38,,22.736,percent of total billed charges,38% of total billed charges,23.9,31.95,,5.136,percent of total billed charges,31.95% of total billed charges,1.38,950.51,
succinylcholine 20 mg/mL Inj Sol [FMC],2551406,CDM,250,RC,J0330,HCPCS,OUTPATIENT,10,ML,77.92,46.752,,66.23,85,,52.984,Percent of total billed charges,85% of total billed charges,1.38,136.6,,3.992,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.38,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,27.39,35.15,,4.832,percent of total billed charges,35.15% of total billed charges,11.18,31.95,,4.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.61,38,,23.688,percent of total billed charges,38% of total billed charges,24.9,31.95,,6.056,percent of total billed charges,31.95% of total billed charges,1.38,66.23,
loperamide 2 mg Cap [FMC],2551430,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.072,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
loperamide 2 mg Cap [FMC],2551430,CDM,250,RC,,,OUTPATIENT,1,EA,3.32,1.992,,2.82,85,,2.256,Percent of total billed charges,85% of total billed charges,1.66,50,,4.368,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.66,50,,13.68,percent of total billed charges,50% of total billed charges,1.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.26,38,,1.008,percent of total billed charges,38% of total billed charges,1.33,40,,0.96,percent of total billed charges,40% of total billed charges,1.06,2.82,
hydrocortisone 2.5% Rectal Crm w/Appl [FMC],2551463,CDM,250,RC,,,OUTPATIENT,30,EA,283.82,170.292,,241.25,85,,193,Percent of total billed charges,85% of total billed charges,141.91,50,,3.992,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,141.91,50,,13.68,percent of total billed charges,50% of total billed charges,90.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,90.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,107.85,38,,86.28,percent of total billed charges,38% of total billed charges,113.53,40,,0.96,percent of total billed charges,40% of total billed charges,90.68,241.25,
hydrocortisone 2.5% Rectal Crm w/Appl [FMC],2551463,CDM,250,RC,,,OUTPATIENT,30,EA,283.82,170.292,,241.25,85,,193,Percent of total billed charges,85% of total billed charges,141.91,50,,445.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,141.91,50,,13.68,percent of total billed charges,50% of total billed charges,90.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,90.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,107.85,38,,86.28,percent of total billed charges,38% of total billed charges,113.53,40,,0.96,percent of total billed charges,40% of total billed charges,90.68,241.25,
hydrocortisone 2.5% Rectal Crm w/Appl [FMC],2551463,CDM,250,RC,,,OUTPATIENT,30,EA,292.5,175.5,,248.63,85,,198.904,Percent of total billed charges,85% of total billed charges,146.25,50,,562.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,146.25,50,,136.816,percent of total billed charges,50% of total billed charges,93.45,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,93.45,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,111.15,38,,88.92,percent of total billed charges,38% of total billed charges,117,40,,0.96,percent of total billed charges,40% of total billed charges,93.45,248.63,
hydrocortisone 2.5% Rectal Crm w/Appl [FMC],2551463,CDM,250,RC,,,OUTPATIENT,30,EA,270.27,162.162,,229.73,85,,183.784,Percent of total billed charges,85% of total billed charges,135.14,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,135.14,50,,1.472,percent of total billed charges,50% of total billed charges,86.35,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,86.35,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.7,38,,82.16,percent of total billed charges,38% of total billed charges,108.11,40,,0.96,percent of total billed charges,40% of total billed charges,86.35,229.73,
anastrozole 1 mg Tab [FMC],2551554,CDM,250,RC,,,OUTPATIENT,1,EA,43.24,25.944,,36.75,85,,29.4,Percent of total billed charges,85% of total billed charges,21.62,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.62,50,,1.2,percent of total billed charges,50% of total billed charges,13.82,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.82,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.43,38,,13.144,percent of total billed charges,38% of total billed charges,17.3,40,,0.96,percent of total billed charges,40% of total billed charges,13.82,36.75,
anastrozole 1 mg Tab [FMC],2551554,CDM,250,RC,,,OUTPATIENT,1,EA,6.73,4.038,,5.72,85,,4.576,Percent of total billed charges,85% of total billed charges,3.37,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.37,50,,12.256,percent of total billed charges,50% of total billed charges,2.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.56,38,,2.048,percent of total billed charges,38% of total billed charges,2.69,40,,0.96,percent of total billed charges,40% of total billed charges,2.15,5.72,
ocular lubricant preserved Sol [FMC],2551596,CDM,250,RC,,,OUTPATIENT,15,EA,18.07,10.842,,15.36,85,,12.288,Percent of total billed charges,85% of total billed charges,9.04,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.04,50,,12.48,percent of total billed charges,50% of total billed charges,5.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.87,38,,5.496,percent of total billed charges,38% of total billed charges,7.23,40,,0.96,percent of total billed charges,40% of total billed charges,5.77,15.36,
ocular lubricant preserved Sol [FMC],2551596,CDM,250,RC,,,OUTPATIENT,15,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,92.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,21.872,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
ocular lubricant preserved Sol [FMC],2551596,CDM,250,RC,,,OUTPATIENT,15,EA,16.05,9.63,,13.64,85,,10.912,Percent of total billed charges,85% of total billed charges,8.03,50,,8.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.03,50,,75.896,percent of total billed charges,50% of total billed charges,5.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.1,38,,4.88,percent of total billed charges,38% of total billed charges,6.42,40,,0.96,percent of total billed charges,40% of total billed charges,5.13,13.64,
ocular lubricant preserved Sol [FMC],2551596,CDM,250,RC,,,OUTPATIENT,15,EA,18.92,11.352,,16.08,85,,12.864,Percent of total billed charges,85% of total billed charges,9.46,50,,11.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.46,50,,72.856,percent of total billed charges,50% of total billed charges,6.04,31.95,,8.744,percent of total billed charges,31.95% of total billed charges,6.04,31.95,,8.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.19,38,,5.752,percent of total billed charges,38% of total billed charges,7.57,40,,10.944,percent of total billed charges,40% of total billed charges,6.04,16.08,
aspirin 300 mg Supp [FMC],2551638,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,12.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,155.544,percent of total billed charges,50% of total billed charges,1.92,31.95,,8.736,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,8.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,10.944,percent of total billed charges,40% of total billed charges,1.92,5.1,
aspirin 325 mg EC UD[FMC],2551646,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12.488,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,155.544,percent of total billed charges,50% of total billed charges,0.96,31.95,,8.736,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,8.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,10.944,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 325 mg EC UD[FMC],2551646,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,141.536,percent of total billed charges,50% of total billed charges,0.96,31.95,,87.424,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,87.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,109.448,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 325 mg Tab [FMC],2551661,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,84.152,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.176,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 325 mg Tab [FMC],2551661,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,84.152,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 325 mg Tab [FMC],2551661,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,84.272,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.832,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.8,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 325 mg Tab [FMC],2551661,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,84.272,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.984,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 81 mg Oral EC Tab [FMC],2551687,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.92,percent of total billed charges,50% of total billed charges,0.96,31.95,,13.976,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,13.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,17.496,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 81 mg Oral EC Tab [FMC],2551687,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,48.496,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,48.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,60.72,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 81 mg Chew Tab [FMC],2551695,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.992,percent of total billed charges,50% of total billed charges,0.96,31.95,,46.552,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,46.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,58.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
aspirin 81 mg Chew Tab [FMC],2551695,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.072,percent of total billed charges,50% of total billed charges,0.96,31.95,,99.392,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,99.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,124.432,percent of total billed charges,40% of total billed charges,0.96,2.55,
azelastine Nasal 137 mcg/inh Spry [FMC],2551703,CDM,250,RC,,,OUTPATIENT,30,UN,34.2,20.52,,29.07,85,,23.256,Percent of total billed charges,85% of total billed charges,17.1,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.1,50,,4.368,percent of total billed charges,50% of total billed charges,10.93,31.95,,99.392,percent of total billed charges,31.95% of total billed charges,10.93,31.95,,99.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13,38,,10.4,percent of total billed charges,38% of total billed charges,13.68,40,,124.432,percent of total billed charges,40% of total billed charges,10.93,29.07,
azelastine Nasal 137 mcg/inh Spry [FMC],2551703,CDM,250,RC,,,OUTPATIENT,30,UN,34.19,20.514,,29.06,85,,23.248,Percent of total billed charges,85% of total billed charges,17.1,50,,36.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.1,50,,3.992,percent of total billed charges,50% of total billed charges,10.92,31.95,,90.44,percent of total billed charges,31.95% of total billed charges,10.92,31.95,,90.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.99,38,,10.392,percent of total billed charges,38% of total billed charges,13.68,40,,113.224,percent of total billed charges,40% of total billed charges,10.92,29.06,
azelastine Nasal 137 mcg/inh Spry [FMC],2551703,CDM,250,RC,,,OUTPATIENT,30,UN,34.19,20.514,,29.06,85,,23.248,Percent of total billed charges,85% of total billed charges,17.1,50,,27.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.1,50,,445.384,percent of total billed charges,50% of total billed charges,10.92,31.95,,53.768,percent of total billed charges,31.95% of total billed charges,10.92,31.95,,53.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.99,38,,10.392,percent of total billed charges,38% of total billed charges,13.68,40,,67.32,percent of total billed charges,40% of total billed charges,10.92,29.06,
azelastine Nasal 137 mcg/inh Spry [FMC],2551703,CDM,250,RC,,,OUTPATIENT,30,UN,342.03,205.218,,290.73,85,,232.584,Percent of total billed charges,85% of total billed charges,171.02,50,,73.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,171.02,50,,562.208,percent of total billed charges,50% of total billed charges,109.28,31.95,,53.768,percent of total billed charges,31.95% of total billed charges,109.28,31.95,,53.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.97,38,,103.976,percent of total billed charges,38% of total billed charges,136.81,40,,67.32,percent of total billed charges,40% of total billed charges,109.28,290.73,
atenolol 50 mg Tab [FMC],2551745,CDM,250,RC,,,OUTPATIENT,1,EA,3.67,2.202,,3.12,85,,2.496,Percent of total billed charges,85% of total billed charges,1.84,50,,73.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.84,50,,1.2,percent of total billed charges,50% of total billed charges,1.17,31.95,,53.848,percent of total billed charges,31.95% of total billed charges,1.17,31.95,,53.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.39,38,,1.112,percent of total billed charges,38% of total billed charges,1.47,40,,67.416,percent of total billed charges,40% of total billed charges,1.17,3.12,
atenolol 50 mg Tab [FMC],2551745,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,53.848,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,53.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,67.416,percent of total billed charges,40% of total billed charges,0.96,2.55,
atracurium 10 mg/mL IV Sol [FMC],2551752,CDM,250,RC,,,OUTPATIENT,5,ML,30.63,18.378,,26.04,85,,20.832,Percent of total billed charges,85% of total billed charges,15.32,50,,3.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.32,50,,1.2,percent of total billed charges,50% of total billed charges,9.79,31.95,,3.144,percent of total billed charges,31.95% of total billed charges,9.79,31.95,,3.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.64,38,,9.312,percent of total billed charges,38% of total billed charges,12.25,40,,3.936,percent of total billed charges,40% of total billed charges,9.79,26.04,
atracurium 10 mg/mL IV Sol [FMC],2551752,CDM,250,RC,,,OUTPATIENT,5,ML,31.2,18.72,,26.52,85,,21.216,Percent of total billed charges,85% of total billed charges,15.6,50,,4.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.6,50,,1.2,percent of total billed charges,50% of total billed charges,9.97,31.95,,1.408,percent of total billed charges,31.95% of total billed charges,9.97,31.95,,1.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.86,38,,9.488,percent of total billed charges,38% of total billed charges,12.48,40,,1.76,percent of total billed charges,40% of total billed charges,9.97,26.52,
atropine 0.4 mg/mL Inj Sol [FMC],2551778,CDM,250,RC,J0461,HCPCS,OUTPATIENT,1,ML,31.2,18.72,,26.52,85,,21.216,Percent of total billed charges,85% of total billed charges,0.14,136.6,,4.216,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,10.97,35.15,,2.552,fee schedule,35.15% of LA custom fee schedule,9.97,31.95,,2.552,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.86,38,,9.488,percent of total billed charges,38% of total billed charges,9.97,31.95,,3.192,Fee Schedule,31.95% of LA custom fee schedule,0.14,26.52,
atropine 0.4 mg/mL Inj Sol [FMC],2551778,CDM,250,RC,J0461,HCPCS,OUTPATIENT,1,ML,46.8,28.08,,39.78,85,,31.824,Percent of total billed charges,85% of total billed charges,0.14,136.6,,7.824,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,16.45,35.15,,2.6,fee schedule,35.15% of LA custom fee schedule,14.95,31.95,,2.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.78,38,,14.224,percent of total billed charges,38% of total billed charges,14.95,31.95,,3.256,Fee Schedule,31.95% of LA custom fee schedule,0.14,39.78,
atropine 0.4 mg/mL Inj Sol [FMC],2551778,CDM,250,RC,J0461,HCPCS,OUTPATIENT,1,ML,43.8,26.28,,37.23,85,,29.784,Percent of total billed charges,85% of total billed charges,0.14,136.6,,5.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,14.888,fee schedule,136.60% of BCBS custom fee schedule,15.4,35.15,,2.792,fee schedule,35.15% of LA custom fee schedule,13.99,31.95,,2.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.64,38,,13.312,percent of total billed charges,38% of total billed charges,13.99,31.95,,3.488,Fee Schedule,31.95% of LA custom fee schedule,0.14,37.23,
atropine 0.1 mg/mL Sol 10 mL  [FMC],2551794,CDM,250,RC,J0461,HCPCS,OUTPATIENT,10,ML,35.1,21.06,,29.84,85,,23.872,Percent of total billed charges,85% of total billed charges,0.14,136.6,,7.592,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,32.504,fee schedule,136.60% of BCBS custom fee schedule,12.34,35.15,,2.552,fee schedule,35.15% of LA custom fee schedule,11.21,31.95,,2.552,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.34,38,,10.672,percent of total billed charges,38% of total billed charges,11.21,31.95,,3.192,Fee Schedule,31.95% of LA custom fee schedule,0.14,29.84,
atropine 0.1 mg/mL Sol 10 mL [FMC],2551794,CDM,250,RC,J0461,HCPCS,OUTPATIENT,10,ML,36.08,21.648,,30.67,85,,24.536,Percent of total billed charges,85% of total billed charges,0.14,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,89.24,fee schedule,136.60% of BCBS custom fee schedule,12.68,35.15,,2.144,fee schedule,35.15% of LA custom fee schedule,11.53,31.95,,483.592,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.71,38,,10.968,percent of total billed charges,38% of total billed charges,11.53,31.95,,1.944,Fee Schedule,31.95% of LA custom fee schedule,0.14,30.67,
atropine 0.1 mg/mL Sol 10 mL [FMC],2551794,CDM,250,RC,J0461,HCPCS,OUTPATIENT,10,ML,40.64,24.384,,34.54,85,,27.632,Percent of total billed charges,85% of total billed charges,0.14,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,17.264,fee schedule,136.60% of BCBS custom fee schedule,14.28,35.15,,0.84,fee schedule,35.15% of LA custom fee schedule,12.98,31.95,,51.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.44,38,,12.352,percent of total billed charges,38% of total billed charges,12.98,31.95,,0.768,Fee Schedule,31.95% of LA custom fee schedule,0.14,34.54,
atropine 0.1 mg/mL Sol 10 mL [FMC],2551794,CDM,250,RC,J0461,HCPCS,OUTPATIENT,10,ML,36.4,21.84,,30.94,85,,24.752,Percent of total billed charges,85% of total billed charges,0.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,17.264,fee schedule,136.60% of BCBS custom fee schedule,12.79,35.15,,284.6,fee schedule,35.15% of LA custom fee schedule,11.63,31.95,,284.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.83,38,,11.064,percent of total billed charges,38% of total billed charges,11.63,31.95,,356.304,Fee Schedule,31.95% of LA custom fee schedule,0.14,30.94,
atropine Ophth 1% Sol [FMC],2551810,CDM,250,RC,,,OUTPATIENT,5,EA,54.67,32.802,,46.47,85,,37.176,Percent of total billed charges,85% of total billed charges,27.34,50,,1.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.34,50,,92.24,percent of total billed charges,50% of total billed charges,17.47,31.95,,359.248,percent of total billed charges,31.95% of total billed charges,17.47,31.95,,359.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.77,38,,16.616,percent of total billed charges,38% of total billed charges,21.87,40,,449.768,percent of total billed charges,40% of total billed charges,17.47,46.47,
atropine Ophth 1% Sol [FMC],2551810,CDM,250,RC,,,OUTPATIENT,5,EA,189.74,113.844,,161.28,85,,129.024,Percent of total billed charges,85% of total billed charges,94.87,50,,18.968,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,94.87,50,,8.944,percent of total billed charges,50% of total billed charges,60.62,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,60.62,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,72.1,38,,57.68,percent of total billed charges,38% of total billed charges,75.9,40,,0.96,percent of total billed charges,40% of total billed charges,60.62,161.28,
atropine Ophth 1% Sol [FMC],2551810,CDM,250,RC,,,OUTPATIENT,5,EA,182.13,109.278,,154.81,85,,123.848,Percent of total billed charges,85% of total billed charges,91.07,50,,22.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,91.07,50,,11.92,percent of total billed charges,50% of total billed charges,58.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,58.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.21,38,,55.368,percent of total billed charges,38% of total billed charges,72.85,40,,0.96,percent of total billed charges,40% of total billed charges,58.19,154.81,
atropine Ophth 1% Sol [FMC],2551810,CDM,250,RC,,,OUTPATIENT,5,EA,388.86,233.316,,330.53,85,,264.424,Percent of total billed charges,85% of total billed charges,194.43,50,,11.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,194.43,50,,12.416,percent of total billed charges,50% of total billed charges,124.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,124.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.77,38,,118.216,percent of total billed charges,38% of total billed charges,155.54,40,,0.96,percent of total billed charges,40% of total billed charges,124.24,330.53,
atropine Ophth 1% Sol [FMC],2551810,CDM,250,RC,,,OUTPATIENT,5,EA,388.86,233.316,,330.53,85,,264.424,Percent of total billed charges,85% of total billed charges,194.43,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,194.43,50,,12.488,percent of total billed charges,50% of total billed charges,124.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,124.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.77,38,,118.216,percent of total billed charges,38% of total billed charges,155.54,40,,0.96,percent of total billed charges,40% of total billed charges,124.24,330.53,
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liq 75 mL [FMC],2551885,CDM,250,RC,,,OUTPATIENT,75,ML,353.83,212.298,,300.76,85,,240.608,Percent of total billed charges,85% of total billed charges,176.92,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,176.92,50,,1.2,percent of total billed charges,50% of total billed charges,113.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,113.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,134.46,38,,107.568,percent of total billed charges,38% of total billed charges,141.53,40,,0.96,percent of total billed charges,40% of total billed charges,113.05,300.76,
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liq 75 mL [FMC],2551885,CDM,250,RC,,,OUTPATIENT,75,ML,210.37,126.222,,178.81,85,,143.048,Percent of total billed charges,85% of total billed charges,105.19,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.19,50,,1.928,percent of total billed charges,50% of total billed charges,67.21,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,67.21,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.94,38,,63.952,percent of total billed charges,38% of total billed charges,84.15,40,,0.96,percent of total billed charges,40% of total billed charges,67.21,178.81,
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liq 75 mL [FMC],2551885,CDM,250,RC,,,OUTPATIENT,75,ML,210.37,126.222,,178.81,85,,143.048,Percent of total billed charges,85% of total billed charges,105.19,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.19,50,,1.2,percent of total billed charges,50% of total billed charges,67.21,31.95,,9.512,percent of total billed charges,31.95% of total billed charges,67.21,31.95,,9.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.94,38,,63.952,percent of total billed charges,38% of total billed charges,84.15,40,,11.904,percent of total billed charges,40% of total billed charges,67.21,178.81,
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liq 75 mL [FMC],2551885,CDM,250,RC,,,OUTPATIENT,75,ML,210.67,126.402,,179.07,85,,143.256,Percent of total billed charges,85% of total billed charges,105.34,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.34,50,,1.2,percent of total billed charges,50% of total billed charges,67.31,31.95,,20.768,percent of total billed charges,31.95% of total billed charges,67.31,31.95,,20.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80.05,38,,64.04,percent of total billed charges,38% of total billed charges,84.27,40,,26,percent of total billed charges,40% of total billed charges,67.31,179.07,
amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liq 75 mL [FMC],2551885,CDM,250,RC,,,OUTPATIENT,75,ML,210.67,126.402,,179.07,85,,143.256,Percent of total billed charges,85% of total billed charges,105.34,50,,1.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.34,50,,1.2,percent of total billed charges,50% of total billed charges,67.31,31.95,,57.024,percent of total billed charges,31.95% of total billed charges,67.31,31.95,,57.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80.05,38,,64.04,percent of total billed charges,38% of total billed charges,84.27,40,,71.392,percent of total billed charges,40% of total billed charges,67.31,179.07,
amoxicillin-clavunate 500 mg-125mg Tab [FMC]C,2551927,CDM,250,RC,,,OUTPATIENT,1,EA,12.3,7.38,,10.46,85,,8.368,Percent of total billed charges,85% of total billed charges,6.15,50,,3.512,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.15,50,,1.2,percent of total billed charges,50% of total billed charges,3.93,31.95,,11.032,percent of total billed charges,31.95% of total billed charges,3.93,31.95,,11.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.67,38,,3.736,percent of total billed charges,38% of total billed charges,4.92,40,,13.808,percent of total billed charges,40% of total billed charges,3.93,10.46,
amoxicillin-clavunate 500 mg-125mg Tab [FMC]C,2551927,CDM,250,RC,,,OUTPATIENT,1,EA,5.5,3.3,,4.68,85,,3.744,Percent of total billed charges,85% of total billed charges,2.75,50,,2.544,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.75,50,,1.2,percent of total billed charges,50% of total billed charges,1.76,31.95,,11.032,percent of total billed charges,31.95% of total billed charges,1.76,31.95,,11.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.09,38,,1.672,percent of total billed charges,38% of total billed charges,2.2,40,,13.808,percent of total billed charges,40% of total billed charges,1.76,4.68,
irbesartan 150 mg Tab [FMC],2551992,CDM,250,RC,,,OUTPATIENT,1,EA,9.98,5.988,,8.48,85,,6.784,Percent of total billed charges,85% of total billed charges,4.99,50,,3.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.99,50,,1.2,percent of total billed charges,50% of total billed charges,3.19,31.95,,58.936,percent of total billed charges,31.95% of total billed charges,3.19,31.95,,58.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.79,38,,3.032,percent of total billed charges,38% of total billed charges,3.99,40,,73.792,percent of total billed charges,40% of total billed charges,3.19,8.48,
irbesartan 150 mg Tab [FMC],2551992,CDM,250,RC,,,OUTPATIENT,1,EA,10.18,6.108,,8.65,85,,6.92,Percent of total billed charges,85% of total billed charges,5.09,50,,1.664,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.09,50,,1.2,percent of total billed charges,50% of total billed charges,3.25,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,3.25,31.95,,1092.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.87,38,,3.096,percent of total billed charges,38% of total billed charges,4.07,40,,0.768,percent of total billed charges,40% of total billed charges,3.25,8.65,
irbesartan 150 mg Tab [FMC],2551992,CDM,250,RC,,,OUTPATIENT,1,EA,10.91,6.546,,9.27,85,,7.416,Percent of total billed charges,85% of total billed charges,5.46,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.46,50,,1.2,percent of total billed charges,50% of total billed charges,3.49,31.95,,1.752,percent of total billed charges,31.95% of total billed charges,3.49,31.95,,894.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.15,38,,3.32,percent of total billed charges,38% of total billed charges,4.36,40,,1.592,percent of total billed charges,40% of total billed charges,3.49,9.27,
irbesartan 150 mg Tab [FMC],2551992,CDM,250,RC,,,OUTPATIENT,1,EA,9.98,5.988,,8.48,85,,6.784,Percent of total billed charges,85% of total billed charges,4.99,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.99,50,,36.36,percent of total billed charges,50% of total billed charges,3.19,31.95,,2.336,percent of total billed charges,31.95% of total billed charges,3.19,31.95,,331.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.79,38,,3.032,percent of total billed charges,38% of total billed charges,3.99,40,,2.128,percent of total billed charges,40% of total billed charges,3.19,8.48,
azaTHIOprine 50 mg Tab [FMC],2552099,CDM,250,RC,J7500,HCPCS,OUTPATIENT,1,EA,7.62,4.572,,6.48,85,,5.184,Percent of total billed charges,85% of total billed charges,17.66,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.66,136.6,,29.08,fee schedule,136.60% of BCBS custom fee schedule,2.68,35.15,,2.248,percent of total billed charges,35.15% of total billed charges,604.49,31.95,,331.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.9,38,,2.32,percent of total billed charges,38% of total billed charges,2.43,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.43,604.49,
azaTHIOprine 50 mg Tab [FMC],2552099,CDM,250,RC,J7500,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,17.66,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.66,136.6,,44.464,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,5.712,percent of total billed charges,35.15% of total billed charges,63.9,31.95,,5.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,7.152,percent of total billed charges,31.95% of total billed charges,0.96,63.9,
brinzolamide Ophth 1% Susp [FMC],2552115,CDM,250,RC,,,OUTPATIENT,10,EA,1113.45,668.07,,946.43,85,,757.144,Percent of total billed charges,85% of total billed charges,556.73,50,,16.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,556.73,50,,27.408,percent of total billed charges,50% of total billed charges,355.75,31.95,,7.616,percent of total billed charges,31.95% of total billed charges,355.75,31.95,,7.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,423.11,38,,338.488,percent of total billed charges,38% of total billed charges,445.38,40,,9.536,percent of total billed charges,40% of total billed charges,355.75,946.43,
brinzolamide Ophth 1% Susp [FMC],2552115,CDM,250,RC,,,OUTPATIENT,10,EA,1405.52,843.312,,1194.69,85,,955.752,Percent of total billed charges,85% of total billed charges,702.76,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,702.76,50,,73.064,percent of total billed charges,50% of total billed charges,449.06,31.95,,7.928,percent of total billed charges,31.95% of total billed charges,449.06,31.95,,7.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,534.1,38,,427.28,percent of total billed charges,38% of total billed charges,562.21,40,,9.928,percent of total billed charges,40% of total billed charges,449.06,1194.69,
Vitamin B Complex with Folic Acid Tab [FMC],2552131,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,73.064,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.992,percent of total billed charges,40% of total billed charges,0.96,2.55,
Vitamin B Complex with Folic Acid Tab [FMC],2552131,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.576,percent of total billed charges,50% of total billed charges,0.96,31.95,,92.184,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,325.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,83.792,percent of total billed charges,40% of total billed charges,0.96,2.55,
cyanocobaLamin 1000MCG Tab [FMC],2552149,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.432,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cyanocobaLamin 1000MCG Tab [FMC],2552149,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.944,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.232,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.536,percent of total billed charges,40% of total billed charges,0.96,2.55,
baclofen 10 mg Tab [FMC],2552172,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.216,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
baclofen 10 mg Tab [FMC],2552172,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.824,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
mupirocin top 2% Oint  22 gm [FMC],2552214,CDM,250,RC,,,OUTPATIENT,22,EA,37.21,22.326,,31.63,85,,25.304,Percent of total billed charges,85% of total billed charges,18.61,50,,14.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.61,50,,5.88,percent of total billed charges,50% of total billed charges,11.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.14,38,,11.312,percent of total billed charges,38% of total billed charges,14.88,40,,0.96,percent of total billed charges,40% of total billed charges,11.89,31.63,
mupirocin top 2% Oint  22 gm [FMC],2552214,CDM,250,RC,,,OUTPATIENT,22,EA,81.25,48.75,,69.06,85,,55.248,Percent of total billed charges,85% of total billed charges,40.63,50,,14.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.63,50,,7.592,percent of total billed charges,50% of total billed charges,25.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,25.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.88,38,,24.704,percent of total billed charges,38% of total billed charges,32.5,40,,0.96,percent of total billed charges,40% of total billed charges,25.96,69.06,
atropine/hyoscyamine/PB/scopolamine 0.0194 mg-0.1037 mg-16.2 mg-0.0065 mg per 5 mL Elixir [FMC],2552289,CDM,250,RC,,,OUTPATIENT,15,ML,223.09,133.854,,189.63,85,,151.704,Percent of total billed charges,85% of total billed charges,111.55,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,111.55,50,,2.4,percent of total billed charges,50% of total billed charges,71.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,71.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,84.77,38,,67.816,percent of total billed charges,38% of total billed charges,89.24,40,,0.96,percent of total billed charges,40% of total billed charges,71.28,189.63,
atropine/hyoscyamine/PB/scopolamine 0.0194 mg-0.1037 mg-16.2 mg-0.0065 mg per 5 mL Elixir [FMC],2552289,CDM,250,RC,,,OUTPATIENT,15,ML,43.16,25.896,,36.69,85,,29.352,Percent of total billed charges,85% of total billed charges,21.58,50,,2.136,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.58,50,,2.4,percent of total billed charges,50% of total billed charges,13.79,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.79,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.4,38,,13.12,percent of total billed charges,38% of total billed charges,17.26,40,,0.96,percent of total billed charges,40% of total billed charges,13.79,36.69,
atropine/hyoscyamine/PB/scopolamine 0.0194 mg-0.1037 mg-16.2 mg-0.0065 mg per 5 mL Elixir [FMC],2552289,CDM,250,RC,,,OUTPATIENT,15,ML,43.16,25.896,,36.69,85,,29.352,Percent of total billed charges,85% of total billed charges,21.58,50,,1.456,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.58,50,,1.2,percent of total billed charges,50% of total billed charges,13.79,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.79,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.4,38,,13.12,percent of total billed charges,38% of total billed charges,17.26,40,,0.96,percent of total billed charges,40% of total billed charges,13.79,36.69,
atropine/hyoscyamine/PB/scopolamine 0.0194 mg-0.1037 mg-16.2 mg-0.0065 mg per 5 mL Elixir [FMC],2552289,CDM,250,RC,,,OUTPATIENT,15,ML,230.59,138.354,,196,85,,156.8,Percent of total billed charges,85% of total billed charges,115.3,50,,2.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115.3,50,,1.472,percent of total billed charges,50% of total billed charges,73.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,73.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,87.62,38,,70.096,percent of total billed charges,38% of total billed charges,92.24,40,,0.96,percent of total billed charges,40% of total billed charges,73.67,196,
diphenhydrAMINE 12.5mg/5ml Liq UD [FMC],2552321,CDM,250,RC,Q0163,HCPCS,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.04,136.6,,2.08,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.04,136.6,,1.76,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,23.232,percent of total billed charges,35.15% of total billed charges,1365.22,31.95,,23.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,29.088,percent of total billed charges,31.95% of total billed charges,0.04,1365.22,
diphenhydrAMINE 12.5mg/5ml Liq UD [FMC],2552321,CDM,250,RC,Q0163,HCPCS,OUTPATIENT,5,ML,6.24,3.744,,5.3,85,,4.24,Percent of total billed charges,85% of total billed charges,0.04,136.6,,1.256,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.04,136.6,,1.824,fee schedule,136.60% of BCBS custom fee schedule,2.19,35.15,,18.584,percent of total billed charges,35.15% of total billed charges,1118.25,31.95,,18.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.37,38,,1.896,percent of total billed charges,38% of total billed charges,1.99,31.95,,23.264,percent of total billed charges,31.95% of total billed charges,0.04,1118.25,
diphenhydrAMINE 12.5mg/5ml Liq UD [FMC],2552321,CDM,250,RC,Q0163,HCPCS,OUTPATIENT,5,ML,8.31,4.986,,7.06,85,,5.648,Percent of total billed charges,85% of total billed charges,0.04,136.6,,1.256,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.04,136.6,,2.928,fee schedule,136.60% of BCBS custom fee schedule,2.92,35.15,,28.408,percent of total billed charges,35.15% of total billed charges,414.07,31.95,,28.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.16,38,,2.528,percent of total billed charges,38% of total billed charges,2.66,31.95,,35.568,percent of total billed charges,31.95% of total billed charges,0.04,414.07,
diphenhydrAMINE 12.5mg/5ml Liq UD [FMC],2552321,CDM,250,RC,Q0163,HCPCS,OUTPATIENT,5,ML,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,0.04,136.6,,1.464,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.04,136.6,,2.6,fee schedule,136.60% of BCBS custom fee schedule,2.81,35.15,,17.512,percent of total billed charges,35.15% of total billed charges,414.07,31.95,,17.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,2.432,percent of total billed charges,38% of total billed charges,2.56,31.95,,21.92,percent of total billed charges,31.95% of total billed charges,0.04,414.07,
olmesartan 40 mg Tab [FMC],2552362,CDM,250,RC,,,OUTPATIENT,1,EA,22.35,13.41,,19,85,,15.2,Percent of total billed charges,85% of total billed charges,11.18,50,,43.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.18,50,,18.968,percent of total billed charges,50% of total billed charges,7.14,31.95,,46.688,percent of total billed charges,31.95% of total billed charges,7.14,31.95,,46.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.49,38,,6.792,percent of total billed charges,38% of total billed charges,8.94,40,,58.448,percent of total billed charges,40% of total billed charges,7.14,19,
olmesartan 40 mg Tab [FMC],2552362,CDM,250,RC,,,OUTPATIENT,1,EA,29.79,17.874,,25.32,85,,20.256,Percent of total billed charges,85% of total billed charges,14.9,50,,43.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.9,50,,22.432,percent of total billed charges,50% of total billed charges,9.52,31.95,,46.688,percent of total billed charges,31.95% of total billed charges,9.52,31.95,,46.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.32,38,,9.056,percent of total billed charges,38% of total billed charges,11.92,40,,58.448,percent of total billed charges,40% of total billed charges,9.52,25.32,
olmesartan 40 mg Tab [FMC],2552362,CDM,250,RC,,,OUTPATIENT,1,EA,31.03,18.618,,26.38,85,,21.104,Percent of total billed charges,85% of total billed charges,15.52,50,,72.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.52,50,,11.44,percent of total billed charges,50% of total billed charges,9.91,31.95,,1.648,percent of total billed charges,31.95% of total billed charges,9.91,31.95,,1.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.79,38,,9.432,percent of total billed charges,38% of total billed charges,12.41,40,,2.064,percent of total billed charges,40% of total billed charges,9.91,26.38,
olmesartan 40 mg Tab [FMC],2552362,CDM,250,RC,,,OUTPATIENT,1,EA,31.22,18.732,,26.54,85,,21.232,Percent of total billed charges,85% of total billed charges,15.61,50,,72.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.61,50,,4.8,percent of total billed charges,50% of total billed charges,9.97,31.95,,2.192,percent of total billed charges,31.95% of total billed charges,9.97,31.95,,2.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.86,38,,9.488,percent of total billed charges,38% of total billed charges,12.49,40,,2.744,percent of total billed charges,40% of total billed charges,9.97,26.54,
dicyclomine 10 mg/mL Inj Sol [FMC],2552370,CDM,250,RC,J0500,HCPCS,OUTPATIENT,2,ML,327.83,196.698,,278.66,85,,222.928,Percent of total billed charges,85% of total billed charges,32.76,136.6,,72.496,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.76,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,115.23,35.15,,3.16,percent of total billed charges,35.15% of total billed charges,406.4,31.95,,3.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.58,38,,99.664,percent of total billed charges,38% of total billed charges,104.74,31.95,,3.952,percent of total billed charges,31.95% of total billed charges,32.76,406.4,
benzonatate 100 mg Cap [FMC],2552404,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,43.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.688,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.368,percent of total billed charges,40% of total billed charges,0.96,2.55,
benzonatate 100 mg Cap [FMC],2552404,CDM,250,RC,,,OUTPATIENT,1,EA,4.81,2.886,,4.09,85,,3.272,Percent of total billed charges,85% of total billed charges,2.41,50,,72.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.41,50,,4.8,percent of total billed charges,50% of total billed charges,1.54,31.95,,5,percent of total billed charges,31.95% of total billed charges,1.54,31.95,,5,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.83,38,,1.464,percent of total billed charges,38% of total billed charges,1.92,40,,6.256,percent of total billed charges,40% of total billed charges,1.54,4.09,
benzonatate 100 mg Cap [FMC],2552404,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,100.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.752,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.704,percent of total billed charges,40% of total billed charges,0.96,2.55,
benzonatate 100 mg Cap [FMC],2552404,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,100.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.848,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.072,percent of total billed charges,40% of total billed charges,0.96,2.55,
benztropine 1 mg Tab [FMC],2552412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.424,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
benztropine 1 mg Tab [FMC],2552412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.512,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
benztropine 1 mg Tab [FMC],2552412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.544,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
benztropine 1 mg Tab [FMC],2552412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.168,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.944,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.176,percent of total billed charges,40% of total billed charges,0.96,2.55,
benztropine 1 mg Tab [FMC],2552412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.664,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.408,percent of total billed charges,40% of total billed charges,0.96,2.55,
benztropine 1 mg Tab [FMC],2552412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.592,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.168,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.456,percent of total billed charges,40% of total billed charges,0.96,2.55,
betamethasone topical valerate 0.1% Cream 15 gm [FMC],2552461,CDM,250,RC,,,OUTPATIENT,15,EA,90.9,54.54,,77.27,85,,61.816,Percent of total billed charges,85% of total billed charges,45.45,50,,102.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.45,50,,1.2,percent of total billed charges,50% of total billed charges,29.04,31.95,,1.872,percent of total billed charges,31.95% of total billed charges,29.04,31.95,,1.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.54,38,,27.632,percent of total billed charges,38% of total billed charges,36.36,40,,2.336,percent of total billed charges,40% of total billed charges,29.04,77.27,
betamethasone topical valerate 0.1% Cream 15 gm [FMC],2552461,CDM,250,RC,,,OUTPATIENT,15,EA,72.7,43.62,,61.8,85,,49.44,Percent of total billed charges,85% of total billed charges,36.35,50,,94.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36.35,50,,1.2,percent of total billed charges,50% of total billed charges,23.23,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,23.23,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.63,38,,22.104,percent of total billed charges,38% of total billed charges,29.08,40,,2.08,percent of total billed charges,40% of total billed charges,23.23,61.8,
betamethasone-clotrimazole Top 0.05%-1% Crm [FMC],2552495,CDM,250,RC,,,OUTPATIENT,15,EA,111.15,66.69,,94.48,85,,75.584,Percent of total billed charges,85% of total billed charges,55.58,50,,2.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,55.58,50,,1.2,percent of total billed charges,50% of total billed charges,35.51,31.95,,4.384,percent of total billed charges,31.95% of total billed charges,35.51,31.95,,325.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.24,38,,33.792,percent of total billed charges,38% of total billed charges,44.46,40,,3.984,percent of total billed charges,40% of total billed charges,35.51,94.48,
betamethasone-clotrimazole Top 0.05%-1% Crm [FMC],2552495,CDM,250,RC,,,OUTPATIENT,15,EA,68.51,41.106,,58.23,85,,46.584,Percent of total billed charges,85% of total billed charges,34.26,50,,6.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34.26,50,,16.384,percent of total billed charges,50% of total billed charges,21.89,31.95,,19.728,percent of total billed charges,31.95% of total billed charges,21.89,31.95,,325.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.03,38,,20.824,percent of total billed charges,38% of total billed charges,27.4,40,,17.936,percent of total billed charges,40% of total billed charges,21.89,58.23,
betamethasone-clotrimazole Top 0.05%-1% Crm [FMC],2552495,CDM,250,RC,,,OUTPATIENT,15,EA,182.65,109.59,,155.25,85,,124.2,Percent of total billed charges,85% of total billed charges,91.33,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,91.33,50,,15.6,percent of total billed charges,50% of total billed charges,58.36,31.95,,12.12,percent of total billed charges,31.95% of total billed charges,58.36,31.95,,12.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.41,38,,55.528,percent of total billed charges,38% of total billed charges,73.06,40,,15.176,percent of total billed charges,40% of total billed charges,58.36,155.25,
betamethasone-clotrimazole topical 0.05%-1% Cre,2552495,CDM,250,RC,,,OUTPATIENT,15,EA,182.65,109.59,,155.25,85,,124.2,Percent of total billed charges,85% of total billed charges,91.33,50,,2.984,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,91.33,50,,2.232,percent of total billed charges,50% of total billed charges,58.36,31.95,,14.336,percent of total billed charges,31.95% of total billed charges,58.36,31.95,,14.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.41,38,,55.528,percent of total billed charges,38% of total billed charges,73.06,40,,17.944,percent of total billed charges,40% of total billed charges,58.36,155.25,
povidone iodine Top 10% Sol [FMC],2552552,CDM,250,RC,,,OUTPATIENT,240,EA,6.44,3.864,,5.47,85,,4.376,Percent of total billed charges,85% of total billed charges,3.22,50,,3.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.22,50,,2.208,percent of total billed charges,50% of total billed charges,2.06,31.95,,7.312,percent of total billed charges,31.95% of total billed charges,2.06,31.95,,7.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.45,38,,1.96,percent of total billed charges,38% of total billed charges,2.58,40,,9.152,percent of total billed charges,40% of total billed charges,2.06,5.47,
povidone iodine Top 10% Sol [FMC],2552552,CDM,250,RC,,,OUTPATIENT,240,EA,8.58,5.148,,7.29,85,,5.832,Percent of total billed charges,85% of total billed charges,4.29,50,,9.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.29,50,,2.208,percent of total billed charges,50% of total billed charges,2.74,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,2.74,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.26,38,,2.608,percent of total billed charges,38% of total billed charges,3.43,40,,3.84,percent of total billed charges,40% of total billed charges,2.74,7.29,
povidone iodine Top 10% Sol [FMC],2552552,CDM,250,RC,,,OUTPATIENT,240,EA,12.35,7.41,,10.5,85,,8.4,Percent of total billed charges,85% of total billed charges,6.18,50,,4.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.18,50,,2.4,percent of total billed charges,50% of total billed charges,3.95,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.95,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.69,38,,3.752,percent of total billed charges,38% of total billed charges,4.94,40,,3.84,percent of total billed charges,40% of total billed charges,3.95,10.5,
povidone iodine Top 10% Sol [FMC],2552552,CDM,250,RC,,,OUTPATIENT,240,EA,10.53,6.318,,8.95,85,,7.16,Percent of total billed charges,85% of total billed charges,5.27,50,,4.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.27,50,,14.04,percent of total billed charges,50% of total billed charges,3.36,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.36,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4,38,,3.2,percent of total billed charges,38% of total billed charges,4.21,40,,3.84,percent of total billed charges,40% of total billed charges,3.36,8.95,
clarithromycin 250 mg Tab [FMC],2552669,CDM,250,RC,,,OUTPATIENT,1,EA,19.55,11.73,,16.62,85,,13.296,Percent of total billed charges,85% of total billed charges,9.78,50,,61.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.78,50,,14.192,percent of total billed charges,50% of total billed charges,6.25,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,6.25,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.43,38,,5.944,percent of total billed charges,38% of total billed charges,7.82,40,,3.84,percent of total billed charges,40% of total billed charges,6.25,16.62,
clarithromycin 250 mg Tab [FMC],2552669,CDM,250,RC,,,OUTPATIENT,1,EA,14.69,8.814,,12.49,85,,9.992,Percent of total billed charges,85% of total billed charges,7.35,50,,13.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.35,50,,14.12,percent of total billed charges,50% of total billed charges,4.69,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4.69,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.58,38,,4.464,percent of total billed charges,38% of total billed charges,5.88,40,,3.84,percent of total billed charges,40% of total billed charges,4.69,12.49,
clarithromycin 250 mg Tab [FMC],2552669,CDM,250,RC,,,OUTPATIENT,1,EA,18.97,11.382,,16.12,85,,12.896,Percent of total billed charges,85% of total billed charges,9.49,50,,177.968,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.49,50,,14.12,percent of total billed charges,50% of total billed charges,6.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.21,38,,5.768,percent of total billed charges,38% of total billed charges,7.59,40,,0.96,percent of total billed charges,40% of total billed charges,6.06,16.12,
"penicillin G benzathine 1,200,000 units/2 mL Sus 2 mL  [FMC]",2552701,CDM,250,RC,J0561,HCPCS,OUTPATIENT,1,ML,406.21,243.726,,345.28,85,,276.224,Percent of total billed charges,85% of total billed charges,30.3,136.6,,21.84,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.3,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,142.78,35.15,,0.904,fee schedule,35.15% of LA custom fee schedule,129.78,31.95,,0.904,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,154.36,38,,123.488,percent of total billed charges,38% of total billed charges,129.78,31.95,,1.136,Fee Schedule,31.95% of LA custom fee schedule,30.3,345.28,
"penicillin G benzathine 600,000 units/mL Sus [FMC]",2552719,CDM,250,RC,J0561,HCPCS,OUTPATIENT,1,ML,214.8,128.88,,182.58,85,,146.064,Percent of total billed charges,85% of total billed charges,30.3,136.6,,1.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.3,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,75.5,35.15,,2.24,fee schedule,35.15% of LA custom fee schedule,68.63,31.95,,2.24,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,81.62,38,,65.296,percent of total billed charges,38% of total billed charges,68.63,31.95,,2.808,Fee Schedule,31.95% of LA custom fee schedule,30.3,182.58,
bisacodyl 10 mg Supp [FMC],2552735,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,1.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,1.2,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.624,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,2.032,percent of total billed charges,40% of total billed charges,1.92,5.1,
bisacodyl 10 mg Supp [FMC],2552735,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,4.136,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.136,percent of total billed charges,50% of total billed charges,1.92,31.95,,2.024,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,2.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,2.528,percent of total billed charges,40% of total billed charges,1.92,5.1,
bisacodyl 5 mg Oral EC Tab [FMC],2552743,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.456,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.328,percent of total billed charges,40% of total billed charges,0.96,2.55,
bisoprolol-hydrochlorothiazide 5 mg-6.25 mg Tab [FMC],2552776,CDM,250,RC,,,OUTPATIENT,1,EA,3.68,2.208,,3.13,85,,2.504,Percent of total billed charges,85% of total billed charges,1.84,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.84,50,,2.08,percent of total billed charges,50% of total billed charges,1.18,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.18,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.4,38,,1.12,percent of total billed charges,38% of total billed charges,1.47,40,,0.96,percent of total billed charges,40% of total billed charges,1.18,3.13,
bisoprolol 5 mg Tab [FMC],2552784,CDM,250,RC,,,OUTPATIENT,1,EA,4.39,2.634,,3.73,85,,2.984,Percent of total billed charges,85% of total billed charges,2.2,50,,6.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.2,50,,2.08,percent of total billed charges,50% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.67,38,,1.336,percent of total billed charges,38% of total billed charges,1.76,40,,0.96,percent of total billed charges,40% of total billed charges,1.4,3.73,
bisoprolol 5 mg Tab,2552784,CDM,250,RC,,,OUTPATIENT,1,EA,4.56,2.736,,3.88,85,,3.104,Percent of total billed charges,85% of total billed charges,2.28,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.28,50,,1.256,percent of total billed charges,50% of total billed charges,1.46,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.46,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.73,38,,1.384,percent of total billed charges,38% of total billed charges,1.82,40,,0.96,percent of total billed charges,40% of total billed charges,1.46,3.88,
zinc oxide topical 16% Oin [FMC],2552834,CDM,250,RC,,,OUTPATIENT,30,EA,7.31,4.386,,6.21,85,,4.968,Percent of total billed charges,85% of total billed charges,3.66,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.66,50,,1.256,percent of total billed charges,50% of total billed charges,2.34,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.34,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.78,38,,2.224,percent of total billed charges,38% of total billed charges,2.92,40,,0.96,percent of total billed charges,40% of total billed charges,2.34,6.21,
zinc oxide topical 16% Oin [FMC],2552834,CDM,250,RC,,,OUTPATIENT,30,EA,6.5,3.9,,5.53,85,,4.424,Percent of total billed charges,85% of total billed charges,3.25,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,1.464,percent of total billed charges,50% of total billed charges,2.08,31.95,,3.64,percent of total billed charges,31.95% of total billed charges,2.08,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,3.312,percent of total billed charges,40% of total billed charges,2.08,5.53,
terbutaline 1 mg/mL Inj Sol [FMC],2552842,CDM,250,RC,J3105,HCPCS,OUTPATIENT,1,ML,15.6,9.36,,13.26,85,,10.608,Percent of total billed charges,85% of total billed charges,21.49,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.49,136.6,,1.328,fee schedule,136.60% of BCBS custom fee schedule,5.48,35.15,,7.696,percent of total billed charges,35.15% of total billed charges,406.4,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.93,38,,4.744,percent of total billed charges,38% of total billed charges,4.98,31.95,,7,percent of total billed charges,31.95% of total billed charges,4.98,406.4,
terbutaline 1 mg/mL Inj Sol [FMC],2552842,CDM,250,RC,J3105,HCPCS,OUTPATIENT,1,ML,70.16,42.096,,59.64,85,,47.712,Percent of total billed charges,85% of total billed charges,21.49,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.49,136.6,,43.104,fee schedule,136.60% of BCBS custom fee schedule,24.66,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,406.4,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.66,38,,21.328,percent of total billed charges,38% of total billed charges,22.42,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,21.49,406.4,
esmolol 10 mg/mL IV Sol [FMC],2552867,CDM,250,RC,,,OUTPATIENT,10,ML,47.42,28.452,,40.31,85,,32.248,Percent of total billed charges,85% of total billed charges,23.71,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.71,50,,43.104,percent of total billed charges,50% of total billed charges,15.15,31.95,,10.992,percent of total billed charges,31.95% of total billed charges,15.15,31.95,,126.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.02,38,,14.416,percent of total billed charges,38% of total billed charges,18.97,40,,9.992,percent of total billed charges,40% of total billed charges,15.15,40.31,
esmolol 10 mg/mL IV Sol [FMC],2552867,CDM,250,RC,,,OUTPATIENT,10,ML,56.08,33.648,,47.67,85,,38.136,Percent of total billed charges,85% of total billed charges,28.04,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.04,50,,43.064,percent of total billed charges,50% of total billed charges,17.92,31.95,,1.424,percent of total billed charges,31.95% of total billed charges,17.92,31.95,,1.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.31,38,,17.048,percent of total billed charges,38% of total billed charges,22.43,40,,1.784,percent of total billed charges,40% of total billed charges,17.92,47.67,
esmolol 10 mg/mL IV Sol [FMC],2552867,CDM,250,RC,,,OUTPATIENT,10,ML,28.6,17.16,,24.31,85,,19.448,Percent of total billed charges,85% of total billed charges,14.3,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.3,50,,72.576,percent of total billed charges,50% of total billed charges,9.14,31.95,,1.408,percent of total billed charges,31.95% of total billed charges,9.14,31.95,,1.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.87,38,,8.696,percent of total billed charges,38% of total billed charges,11.44,40,,1.768,percent of total billed charges,40% of total billed charges,9.14,24.31,
bumetanide 0.25 mg/mL Inj Sol [FMC],2552891,CDM,250,RC,,,OUTPATIENT,4,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,13.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,72.496,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.408,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,1.76,percent of total billed charges,40% of total billed charges,3.83,10.2,
bumetanide 0.25 mg/mL Inj Sol [FMC],2552891,CDM,250,RC,,,OUTPATIENT,4,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,17.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,72.496,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,1.92,percent of total billed charges,40% of total billed charges,3.83,10.2,
bumetanide 0.25 mg/mL Inj Sol [FMC],2552891,CDM,250,RC,,,OUTPATIENT,4,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,23.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,43.104,percent of total billed charges,50% of total billed charges,3.83,31.95,,8.968,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,8.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,11.232,percent of total billed charges,40% of total billed charges,3.83,10.2,
bumetanide 0.25 mg/mL Inj Sol [FMC],2552891,CDM,250,RC,,,OUTPATIENT,4,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,72.576,percent of total billed charges,50% of total billed charges,3.83,31.95,,9.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,9.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,11.352,percent of total billed charges,40% of total billed charges,3.83,10.2,
bumetanide 0.25 mg/mL Inj Sol [FMC],2552891,CDM,250,RC,,,OUTPATIENT,4,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,100.68,percent of total billed charges,50% of total billed charges,3.83,31.95,,9.024,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,9.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,11.296,percent of total billed charges,40% of total billed charges,3.83,10.2,
bumetanide 1 mg Tab [FMC],2552909,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,100.568,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,11.296,percent of total billed charges,40% of total billed charges,0.96,2.55,
bumetanide 1 mg Tab [FMC],2552909,CDM,250,RC,,,OUTPATIENT,1,EA,3.55,2.13,,3.02,85,,2.416,Percent of total billed charges,85% of total billed charges,1.78,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.78,50,,6.008,percent of total billed charges,50% of total billed charges,1.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.35,38,,1.08,percent of total billed charges,38% of total billed charges,1.42,40,,0.96,percent of total billed charges,40% of total billed charges,1.13,3.02,
bumetanide 1 mg Tab [FMC],2552909,CDM,250,RC,,,OUTPATIENT,1,EA,8.77,5.262,,7.45,85,,5.96,Percent of total billed charges,85% of total billed charges,4.39,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.39,50,,5.68,percent of total billed charges,50% of total billed charges,2.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.33,38,,2.664,percent of total billed charges,38% of total billed charges,3.51,40,,0.96,percent of total billed charges,40% of total billed charges,2.8,7.45,
bumetanide 1 mg Tab [FMC],2552909,CDM,250,RC,,,OUTPATIENT,1,EA,6.36,3.816,,5.41,85,,4.328,Percent of total billed charges,85% of total billed charges,3.18,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.18,50,,3.504,percent of total billed charges,50% of total billed charges,2.03,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.03,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.42,38,,1.936,percent of total billed charges,38% of total billed charges,2.54,40,,0.96,percent of total billed charges,40% of total billed charges,2.03,5.41,
bumetanide 1 mg Tab [FMC],2552909,CDM,250,RC,,,OUTPATIENT,1,EA,7.91,4.746,,6.72,85,,5.376,Percent of total billed charges,85% of total billed charges,3.96,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.96,50,,3.32,percent of total billed charges,50% of total billed charges,2.53,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,2.53,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.01,38,,2.408,percent of total billed charges,38% of total billed charges,3.16,40,,1.712,percent of total billed charges,40% of total billed charges,2.53,6.72,
bumetanide 1 mg Tab [FMC],2552909,CDM,250,RC,,,OUTPATIENT,1,EA,4.16,2.496,,3.54,85,,2.832,Percent of total billed charges,85% of total billed charges,2.08,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.08,50,,1.792,percent of total billed charges,50% of total billed charges,1.33,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,1.33,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.58,38,,1.264,percent of total billed charges,38% of total billed charges,1.66,40,,1.168,percent of total billed charges,40% of total billed charges,1.33,3.54,
busPIRone 5 mg Tab [FMC],2552958,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.592,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.664,percent of total billed charges,40% of total billed charges,0.96,2.55,
busPIRone 5 mg Tab [FMC],2552958,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,102.704,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.664,percent of total billed charges,40% of total billed charges,0.96,2.55,
busPIRone 5 mg Tab [FMC],2552958,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,94.12,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.8,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.008,percent of total billed charges,40% of total billed charges,0.96,2.55,
busPIRone 5 mg Tab,2552958,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.04,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.8,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.008,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium chloride 100 mg/mL Inj Sol [FMC],2553014,CDM,250,RC,J0610,HCPCS,OUTPATIENT,10,ML,40.95,24.57,,34.81,85,,27.848,Percent of total billed charges,85% of total billed charges,20.48,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.48,50,,6.688,percent of total billed charges,50% of total billed charges,14.39,35.15,,0.936,fee schedule,35.15% of LA custom fee schedule,13.08,31.95,,0.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.56,38,,12.448,percent of total billed charges,38% of total billed charges,13.08,31.95,,1.168,Fee Schedule,31.95% of LA custom fee schedule,13.08,34.81,
calcium chloride 100 mg/mL Inj Sol [FMC],2553014,CDM,250,RC,J0610,HCPCS,OUTPATIENT,10,ML,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,19.5,50,,11.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.5,50,,1.6,percent of total billed charges,50% of total billed charges,13.71,35.15,,0.848,fee schedule,35.15% of LA custom fee schedule,12.46,31.95,,0.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,12.46,31.95,,1.056,Fee Schedule,31.95% of LA custom fee schedule,12.46,33.15,
calcium gluconate 100 mg/mL Inj Sol [FMC],2553097,CDM,250,RC,J0612,HCPCS,OUTPATIENT,10,ML,12.95,7.77,,11.01,85,,8.808,Percent of total billed charges,85% of total billed charges,0.08,136.6,,14.496,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,4.55,35.15,,27.544,percent of total billed charges,35.15% of total billed charges,23.96,31.95,,27.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.92,38,,3.936,percent of total billed charges,38% of total billed charges,4.14,31.95,,34.48,percent of total billed charges,31.95% of total billed charges,0.08,23.96,
calcium gluconate 100 mg/mL Inj Sol [FMC],2553097,CDM,250,RC,J0612,HCPCS,OUTPATIENT,10,ML,27.38,16.428,,23.27,85,,18.616,Percent of total billed charges,85% of total billed charges,0.08,136.6,,4.392,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,9.62,35.15,,27.544,percent of total billed charges,35.15% of total billed charges,6.39,31.95,,27.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.4,38,,8.32,percent of total billed charges,38% of total billed charges,8.75,31.95,,34.48,percent of total billed charges,31.95% of total billed charges,0.08,23.27,
calcium gluconate 100 mg/mL Inj Sol [FMC],2553097,CDM,250,RC,J0612,HCPCS,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.08,136.6,,2.736,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,27.512,percent of total billed charges,35.15% of total billed charges,38.34,31.95,,27.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,34.448,percent of total billed charges,31.95% of total billed charges,0.08,38.34,
calcium gluconate 100 mg/mL Inj Sol [FMC],2553097,CDM,250,RC,J0612,HCPCS,OUTPATIENT,10,ML,39.08,23.448,,33.22,85,,26.576,Percent of total billed charges,85% of total billed charges,0.08,136.6,,2.776,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,2.984,fee schedule,136.60% of BCBS custom fee schedule,13.74,35.15,,46.376,percent of total billed charges,35.15% of total billed charges,158.15,31.95,,46.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.85,38,,11.88,percent of total billed charges,38% of total billed charges,12.49,31.95,,58.064,percent of total billed charges,31.95% of total billed charges,0.08,158.15,
captopril 12.5 mg Tab [FMC],2553170,CDM,250,RC,,,OUTPATIENT,1,EA,5.58,3.348,,4.74,85,,3.792,Percent of total billed charges,85% of total billed charges,2.79,50,,2.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.79,50,,2.984,percent of total billed charges,50% of total billed charges,1.78,31.95,,46.328,percent of total billed charges,31.95% of total billed charges,1.78,31.95,,46.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.12,38,,1.696,percent of total billed charges,38% of total billed charges,2.23,40,,58,percent of total billed charges,40% of total billed charges,1.78,4.74,
captopril 12.5 mg Tab [FMC],2553170,CDM,250,RC,,,OUTPATIENT,1,EA,5.52,3.312,,4.69,85,,3.752,Percent of total billed charges,85% of total billed charges,2.76,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.76,50,,3.816,percent of total billed charges,50% of total billed charges,1.76,31.95,,46.328,percent of total billed charges,31.95% of total billed charges,1.76,31.95,,46.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.1,38,,1.68,percent of total billed charges,38% of total billed charges,2.21,40,,58,percent of total billed charges,40% of total billed charges,1.76,4.69,
captopril 12.5 mg Tab [FMC],2553170,CDM,250,RC,,,OUTPATIENT,1,EA,5.51,3.306,,4.68,85,,3.744,Percent of total billed charges,85% of total billed charges,2.76,50,,221.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.76,50,,9.576,percent of total billed charges,50% of total billed charges,1.76,31.95,,27.544,percent of total billed charges,31.95% of total billed charges,1.76,31.95,,27.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.09,38,,1.672,percent of total billed charges,38% of total billed charges,2.2,40,,34.48,percent of total billed charges,40% of total billed charges,1.76,4.68,
captopril 25 mg Tab [FMC],2553196,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,87.736,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,4.384,percent of total billed charges,50% of total billed charges,1.92,31.95,,46.376,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,46.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,58.064,percent of total billed charges,40% of total billed charges,1.92,5.1,
sucralfate 1 g/10 mL Oral Susp [FMC],2553238,CDM,250,RC,,,OUTPATIENT,10,ML,35.09,21.054,,29.83,85,,23.864,Percent of total billed charges,85% of total billed charges,17.55,50,,159.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.55,50,,4.384,percent of total billed charges,50% of total billed charges,11.21,31.95,,64.336,percent of total billed charges,31.95% of total billed charges,11.21,31.95,,64.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.33,38,,10.664,percent of total billed charges,38% of total billed charges,14.04,40,,80.544,percent of total billed charges,40% of total billed charges,11.21,29.83,
sucralfate 1 g/10 mL Oral Susp [FMC],2553238,CDM,250,RC,,,OUTPATIENT,10,ML,35.47,21.282,,30.15,85,,24.12,Percent of total billed charges,85% of total billed charges,17.74,50,,159.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.74,50,,61.504,percent of total billed charges,50% of total billed charges,11.33,31.95,,64.264,percent of total billed charges,31.95% of total billed charges,11.33,31.95,,64.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.48,38,,10.784,percent of total billed charges,38% of total billed charges,14.19,40,,80.456,percent of total billed charges,40% of total billed charges,11.33,30.15,
sucralfate 1 g/10 mL Oral Susp [FMC],2553238,CDM,250,RC,,,OUTPATIENT,10,ML,35.3,21.18,,30.01,85,,24.008,Percent of total billed charges,85% of total billed charges,17.65,50,,3.464,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.65,50,,13.264,percent of total billed charges,50% of total billed charges,11.28,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,11.28,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.41,38,,10.728,percent of total billed charges,38% of total billed charges,14.12,40,,4.8,percent of total billed charges,40% of total billed charges,11.28,30.01,
sucralfate 1 g/10 mL Oral Susp [FMC],2553238,CDM,250,RC,,,OUTPATIENT,10,ML,35.3,21.18,,30.01,85,,24.008,Percent of total billed charges,85% of total billed charges,17.65,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.65,50,,177.968,percent of total billed charges,50% of total billed charges,11.28,31.95,,3.624,percent of total billed charges,31.95% of total billed charges,11.28,31.95,,3.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.41,38,,10.728,percent of total billed charges,38% of total billed charges,14.12,40,,4.544,percent of total billed charges,40% of total billed charges,11.28,30.01,
carBAMazepine 100 mg Chew Tab [FMC],2553246,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,21.84,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.24,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.8,percent of total billed charges,40% of total billed charges,0.96,2.55,
carBAMazepine 100 mg Chew Tab [FMC],2553246,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.672,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.12,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.656,percent of total billed charges,40% of total billed charges,0.96,2.55,
carBAMazepine 200 mg Tab [FMC],2553253,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.672,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.144,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.432,percent of total billed charges,40% of total billed charges,0.96,2.55,
carBAMazepine 200 mg Tab [FMC],2553253,CDM,250,RC,,,OUTPATIENT,1,EA,5.34,3.204,,4.54,85,,3.632,Percent of total billed charges,85% of total billed charges,2.67,50,,1.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.67,50,,4.136,percent of total billed charges,50% of total billed charges,1.71,31.95,,1.016,percent of total billed charges,31.95% of total billed charges,1.71,31.95,,1.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.03,38,,1.624,percent of total billed charges,38% of total billed charges,2.14,40,,1.272,percent of total billed charges,40% of total billed charges,1.71,4.54,
carBAMazepine 200 mg Tab [FMC],2553253,CDM,250,RC,,,OUTPATIENT,1,EA,3.64,2.184,,3.09,85,,2.472,Percent of total billed charges,85% of total billed charges,1.82,50,,1.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.82,50,,1.2,percent of total billed charges,50% of total billed charges,1.16,31.95,,13.664,percent of total billed charges,31.95% of total billed charges,1.16,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.38,38,,1.104,percent of total billed charges,38% of total billed charges,1.46,40,,12.416,percent of total billed charges,40% of total billed charges,1.16,3.09,
carBAMazepine 200 mg Tab [FMC],2553253,CDM,250,RC,,,OUTPATIENT,1,EA,5.2,3.12,,4.42,85,,3.536,Percent of total billed charges,85% of total billed charges,2.6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.6,50,,1.2,percent of total billed charges,50% of total billed charges,1.66,31.95,,120.656,percent of total billed charges,31.95% of total billed charges,1.66,31.95,,126.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.08,40,,109.672,percent of total billed charges,40% of total billed charges,1.66,4.42,
carBAMazepine 200 mg Tab [FMC],2553253,CDM,250,RC,,,OUTPATIENT,1,EA,5.2,3.12,,4.42,85,,3.536,Percent of total billed charges,85% of total billed charges,2.6,50,,1.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.6,50,,6.976,percent of total billed charges,50% of total billed charges,1.66,31.95,,65.624,percent of total billed charges,31.95% of total billed charges,1.66,31.95,,65.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.08,40,,82.16,percent of total billed charges,40% of total billed charges,1.66,4.42,
dilTIAZem 120 mg/24 hours ER Cap [FMC],2553279,CDM,250,RC,,,OUTPATIENT,1,EA,3.14,1.884,,2.67,85,,2.136,Percent of total billed charges,85% of total billed charges,1.57,50,,1.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.57,50,,1.2,percent of total billed charges,50% of total billed charges,1,31.95,,60.144,percent of total billed charges,31.95% of total billed charges,1,31.95,,60.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.19,38,,0.952,percent of total billed charges,38% of total billed charges,1.26,40,,75.296,percent of total billed charges,40% of total billed charges,1,2.67,
dilTIAZem 180 mg/24 hours ER Cap [FMC],2553287,CDM,250,RC,,,OUTPATIENT,1,EA,3.14,1.884,,2.67,85,,2.136,Percent of total billed charges,85% of total billed charges,1.57,50,,1.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.57,50,,1.2,percent of total billed charges,50% of total billed charges,1,31.95,,1.304,percent of total billed charges,31.95% of total billed charges,1,31.95,,1.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.19,38,,0.952,percent of total billed charges,38% of total billed charges,1.26,40,,1.632,percent of total billed charges,40% of total billed charges,1,2.67,
doxazosin 4 mg Tab [FMC],2553329,CDM,250,RC,,,OUTPATIENT,1,EA,3.65,2.19,,3.1,85,,2.48,Percent of total billed charges,85% of total billed charges,1.83,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.83,50,,1.2,percent of total billed charges,50% of total billed charges,1.17,31.95,,4.272,percent of total billed charges,31.95% of total billed charges,1.17,31.95,,4.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.39,38,,1.112,percent of total billed charges,38% of total billed charges,1.46,40,,5.344,percent of total billed charges,40% of total billed charges,1.17,3.1,
doxazosin 4 mg Tab [FMC],2553329,CDM,250,RC,,,OUTPATIENT,1,EA,3.31,1.986,,2.81,85,,2.248,Percent of total billed charges,85% of total billed charges,1.66,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.66,50,,1.2,percent of total billed charges,50% of total billed charges,1.06,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.06,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.26,38,,1.008,percent of total billed charges,38% of total billed charges,1.32,40,,1.28,percent of total billed charges,40% of total billed charges,1.06,2.81,
cloNIDine 0.1 mg/24 hr Transderm ER Film [FMC],2553402,CDM,250,RC,,,OUTPATIENT,1,EA,107.76,64.656,,91.6,85,,73.28,Percent of total billed charges,85% of total billed charges,53.88,50,,4.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53.88,50,,1.6,percent of total billed charges,50% of total billed charges,34.43,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,34.43,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.95,38,,32.76,percent of total billed charges,38% of total billed charges,43.1,40,,1.28,percent of total billed charges,40% of total billed charges,34.43,91.6,
cloNIDine 0.1 mg/24 hr Transderm ER Film [FMC],2553402,CDM,250,RC,,,OUTPATIENT,1,EA,107.76,64.656,,91.6,85,,73.28,Percent of total billed charges,85% of total billed charges,53.88,50,,4.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53.88,50,,1.6,percent of total billed charges,50% of total billed charges,34.43,31.95,,5.616,percent of total billed charges,31.95% of total billed charges,34.43,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.95,38,,32.76,percent of total billed charges,38% of total billed charges,43.1,40,,5.104,percent of total billed charges,40% of total billed charges,34.43,91.6,
cloNIDine 0.1 mg/24 hr Transderm ER Film [FMC],2553402,CDM,250,RC,,,OUTPATIENT,1,EA,107.65,64.59,,91.5,85,,73.2,Percent of total billed charges,85% of total billed charges,53.83,50,,5.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53.83,50,,1.6,percent of total billed charges,50% of total billed charges,34.39,31.95,,8.736,percent of total billed charges,31.95% of total billed charges,34.39,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.91,38,,32.728,percent of total billed charges,38% of total billed charges,43.06,40,,7.944,percent of total billed charges,40% of total billed charges,34.39,91.5,
cloNIDine 0.2 mg/24 hr Transderm ER Film [FMC],2553410,CDM,250,RC,,,OUTPATIENT,1,EA,181.44,108.864,,154.22,85,,123.376,Percent of total billed charges,85% of total billed charges,90.72,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90.72,50,,1.6,percent of total billed charges,50% of total billed charges,57.97,31.95,,6.84,percent of total billed charges,31.95% of total billed charges,57.97,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.95,38,,55.16,percent of total billed charges,38% of total billed charges,72.58,40,,6.216,percent of total billed charges,40% of total billed charges,57.97,154.22,
cloNIDine 0.2 mg/24 hr Transderm ER Film [FMC],2553410,CDM,250,RC,,,OUTPATIENT,1,EA,181.24,108.744,,154.05,85,,123.24,Percent of total billed charges,85% of total billed charges,90.62,50,,1.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90.62,50,,13.632,percent of total billed charges,50% of total billed charges,57.91,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,57.91,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.87,38,,55.096,percent of total billed charges,38% of total billed charges,72.5,40,,1.28,percent of total billed charges,40% of total billed charges,57.91,154.05,
cloNIDine 0.2 mg/24 hr Transderm ER Film [FMC],2553410,CDM,250,RC,,,OUTPATIENT,1,EA,181.24,108.744,,154.05,85,,123.24,Percent of total billed charges,85% of total billed charges,90.62,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90.62,50,,17.672,percent of total billed charges,50% of total billed charges,57.91,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,57.91,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.87,38,,55.096,percent of total billed charges,38% of total billed charges,72.5,40,,1.28,percent of total billed charges,40% of total billed charges,57.91,154.05,
cloNIDine 0.2 mg/24 hr Transderm ER Film [FMC],2553410,CDM,250,RC,,,OUTPATIENT,1,EA,107.76,64.656,,91.6,85,,73.28,Percent of total billed charges,85% of total billed charges,53.88,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53.88,50,,23.408,percent of total billed charges,50% of total billed charges,34.43,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,34.43,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.95,38,,32.76,percent of total billed charges,38% of total billed charges,43.1,40,,2.384,percent of total billed charges,40% of total billed charges,34.43,91.6,
cloNIDine 0.2 mg/24 hr Transderm ER Film [FMC],2553410,CDM,250,RC,,,OUTPATIENT,1,EA,181.44,108.864,,154.22,85,,123.376,Percent of total billed charges,85% of total billed charges,90.72,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90.72,50,,1.2,percent of total billed charges,50% of total billed charges,57.97,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,57.97,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.95,38,,55.16,percent of total billed charges,38% of total billed charges,72.58,40,,2.384,percent of total billed charges,40% of total billed charges,57.97,154.22,
cloNIDine 0.3 mg/24 hr Transderm ER Film [FMC],2553428,CDM,250,RC,,,OUTPATIENT,1,EA,251.7,151.02,,213.95,85,,171.16,Percent of total billed charges,85% of total billed charges,125.85,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,125.85,50,,1.2,percent of total billed charges,50% of total billed charges,80.42,31.95,,2.44,percent of total billed charges,31.95% of total billed charges,80.42,31.95,,2.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95.65,38,,76.52,percent of total billed charges,38% of total billed charges,100.68,40,,3.056,percent of total billed charges,40% of total billed charges,80.42,213.95,
cloNIDine 0.3 mg/24 hr Transderm ER Film [FMC],2553428,CDM,250,RC,,,OUTPATIENT,1,EA,251.42,150.852,,213.71,85,,170.968,Percent of total billed charges,85% of total billed charges,125.71,50,,2.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,125.71,50,,1.2,percent of total billed charges,50% of total billed charges,80.33,31.95,,6.12,percent of total billed charges,31.95% of total billed charges,80.33,31.95,,6.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95.54,38,,76.432,percent of total billed charges,38% of total billed charges,100.57,40,,7.664,percent of total billed charges,40% of total billed charges,80.33,213.71,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,2.8,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,2.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.504,Fee Schedule,31.95% of LA custom fee schedule,1.09,10.2,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,2.8,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,2.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.504,Fee Schedule,31.95% of LA custom fee schedule,1.09,10.2,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,39.304,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,39.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,49.2,Fee Schedule,31.95% of LA custom fee schedule,1.09,10.2,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,8.472,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,8.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,10.608,Fee Schedule,31.95% of LA custom fee schedule,1.09,10.2,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.09,136.6,,2.264,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,113.72,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,113.72,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,142.368,Fee Schedule,31.95% of LA custom fee schedule,1.09,10.2,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.09,136.6,,1.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,13.952,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,13.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,17.472,Fee Schedule,31.95% of LA custom fee schedule,1.09,10.2,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.09,136.6,,2.296,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.064,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.336,Fee Schedule,31.95% of LA custom fee schedule,1.09,10.2,
ceFAZolin 1 g Inj IM_IVPB [FMC],2553436,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,EA,24.38,14.628,,20.72,85,,16.576,Percent of total billed charges,85% of total billed charges,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.57,35.15,,1.064,fee schedule,35.15% of LA custom fee schedule,7.79,31.95,,1.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.26,38,,7.408,percent of total billed charges,38% of total billed charges,7.79,31.95,,1.336,Fee Schedule,31.95% of LA custom fee schedule,1.09,20.72,
cefuroxime 1.5 g Inj [FMC],2553519,CDM,250,RC,J0697,HCPCS,OUTPATIENT,1,EA,43.68,26.208,,37.13,85,,29.704,Percent of total billed charges,85% of total billed charges,2.81,136.6,,78.136,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.81,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,15.35,35.15,,2.64,fee schedule,35.15% of LA custom fee schedule,13.96,31.95,,2.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.6,38,,13.28,percent of total billed charges,38% of total billed charges,13.96,31.95,,3.304,Fee Schedule,31.95% of LA custom fee schedule,2.81,37.13,
celecoxib 100 mg Cap [FMC],2553576,CDM,250,RC,,,OUTPATIENT,1,EA,15.01,9.006,,12.76,85,,10.208,Percent of total billed charges,85% of total billed charges,7.51,50,,4.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.51,50,,1.2,percent of total billed charges,50% of total billed charges,4.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,4.56,percent of total billed charges,38% of total billed charges,6,40,,0.96,percent of total billed charges,40% of total billed charges,4.8,12.76,
celecoxib 100 mg Cap [FMC],2553576,CDM,250,RC,,,OUTPATIENT,1,EA,14.19,8.514,,12.06,85,,9.648,Percent of total billed charges,85% of total billed charges,7.1,50,,9.608,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.1,50,,1.6,percent of total billed charges,50% of total billed charges,4.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.39,38,,4.312,percent of total billed charges,38% of total billed charges,5.68,40,,0.96,percent of total billed charges,40% of total billed charges,4.53,12.06,
citalopram 20 mg Tab [FMC],2553592,CDM,250,RC,,,OUTPATIENT,1,EA,8.75,5.25,,7.44,85,,5.952,Percent of total billed charges,85% of total billed charges,4.38,50,,2.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.38,50,,1.6,percent of total billed charges,50% of total billed charges,2.8,31.95,,4.456,percent of total billed charges,31.95% of total billed charges,2.8,31.95,,4.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.33,38,,2.664,percent of total billed charges,38% of total billed charges,3.5,40,,5.584,percent of total billed charges,40% of total billed charges,2.8,7.44,
citalopram 20 mg Tab [FMC],2553592,CDM,250,RC,,,OUTPATIENT,1,EA,8.3,4.98,,7.06,85,,5.648,Percent of total billed charges,85% of total billed charges,4.15,50,,4.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.15,50,,1.6,percent of total billed charges,50% of total billed charges,2.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.15,38,,2.52,percent of total billed charges,38% of total billed charges,3.32,40,,0.96,percent of total billed charges,40% of total billed charges,2.65,7.06,
cephalexin 500 mg Cap [FMC],2553683,CDM,250,RC,,,OUTPATIENT,1,EA,4.47,2.682,,3.8,85,,3.04,Percent of total billed charges,85% of total billed charges,2.24,50,,17.368,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.24,50,,1.6,percent of total billed charges,50% of total billed charges,1.43,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.43,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.7,38,,1.36,percent of total billed charges,38% of total billed charges,1.79,40,,0.96,percent of total billed charges,40% of total billed charges,1.43,3.8,
cephalexin 500 mg Cap [FMC],2553683,CDM,250,RC,,,OUTPATIENT,1,EA,3.97,2.382,,3.37,85,,2.696,Percent of total billed charges,85% of total billed charges,1.99,50,,20.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.99,50,,1.6,percent of total billed charges,50% of total billed charges,1.27,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.27,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.51,38,,1.208,percent of total billed charges,38% of total billed charges,1.59,40,,0.96,percent of total billed charges,40% of total billed charges,1.27,3.37,
fosphenytoin (PE) 500 mg/10 mL Inj Sol [FMC],2553691,CDM,250,RC,Q2009,HCPCS,OUTPATIENT,10,ML,48.59,29.154,,41.3,85,,33.04,Percent of total billed charges,85% of total billed charges,6.79,136.6,,17.76,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.79,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,17.08,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,3.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.46,38,,14.768,percent of total billed charges,38% of total billed charges,15.52,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,3.02,41.3,
fosphenytoin (PE) 500 mg/10 mL Inj Sol [FMC],2553691,CDM,250,RC,Q2009,HCPCS,OUTPATIENT,10,ML,429.07,257.442,,364.71,85,,291.768,Percent of total billed charges,85% of total billed charges,6.79,136.6,,23.792,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.79,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,150.82,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,158.15,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.05,38,,130.44,percent of total billed charges,38% of total billed charges,137.09,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,6.79,364.71,
benzocaine/butamben/tetracaine Top Aer 56 g [FMC],2553774,CDM,250,RC,,,OUTPATIENT,56,UN,256.75,154.05,,218.24,85,,174.592,Percent of total billed charges,85% of total billed charges,128.38,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,128.38,50,,1.2,percent of total billed charges,50% of total billed charges,82.03,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,82.03,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,97.57,38,,78.056,percent of total billed charges,38% of total billed charges,102.7,40,,1.28,percent of total billed charges,40% of total billed charges,82.03,218.24,
benzocaine/butamben/tetracaine topical Aer 20 g [FMC],2553774,CDM,250,RC,,,OUTPATIENT,56,UN,235.3,141.18,,200.01,85,,160.008,Percent of total billed charges,85% of total billed charges,117.65,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,117.65,50,,1.2,percent of total billed charges,50% of total billed charges,75.18,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,75.18,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,89.41,38,,71.528,percent of total billed charges,38% of total billed charges,94.12,40,,1.28,percent of total billed charges,40% of total billed charges,75.18,200.01,
chlordiazePOXIDE-clidinium 5 mg-2.5 mg Cap [FMC],2553824,CDM,250,RC,,,OUTPATIENT,1,EA,5.1,3.06,,4.34,85,,3.472,Percent of total billed charges,85% of total billed charges,2.55,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.55,50,,1.2,percent of total billed charges,50% of total billed charges,1.63,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.63,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.94,38,,1.552,percent of total billed charges,38% of total billed charges,2.04,40,,1.28,percent of total billed charges,40% of total billed charges,1.63,4.34,
chlordiazePOXIDE-clidinium 5 mg-2.5 mg Cap [FMC],2553824,CDM,250,RC,,,OUTPATIENT,1,EA,16.71,10.026,,14.2,85,,11.36,Percent of total billed charges,85% of total billed charges,8.36,50,,1.912,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.36,50,,1.2,percent of total billed charges,50% of total billed charges,5.34,31.95,,12.136,percent of total billed charges,31.95% of total billed charges,5.34,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.35,38,,5.08,percent of total billed charges,38% of total billed charges,6.68,40,,11.032,percent of total billed charges,40% of total billed charges,5.34,14.2,
chlordiazePOXIDE 25 mg Cap [FMC],2553840,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,11.216,percent of total billed charges,50% of total billed charges,1.28,31.95,,4.84,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,4.4,percent of total billed charges,40% of total billed charges,1.28,3.4,
chlordiazePOXIDE 25 mg Cap [FMC],2553840,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,2.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,14.496,percent of total billed charges,50% of total billed charges,1.28,31.95,,8.712,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,8.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,10.904,percent of total billed charges,40% of total billed charges,1.28,3.4,
dexamethasone 10 mg/mL Inj Sol [FMC],2553857,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,7.488,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,11.296,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,11.296,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,14.136,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
dexamethasone 10 mg/mL Inj Sol [FMC],2553857,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.488,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,8.76,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,14.952,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,14.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,18.72,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
chlorproMAZINE 25 mg Tab [FMC],2553865,CDM,250,RC,Q0161,HCPCS,OUTPATIENT,1,EA,19.96,11.976,,16.97,85,,13.576,Percent of total billed charges,85% of total billed charges,2.79,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.79,136.6,,1.64,fee schedule,136.60% of BCBS custom fee schedule,7.02,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,3.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.58,38,,6.064,percent of total billed charges,38% of total billed charges,6.38,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,2.79,16.97,
chlorproMAZINE 25 mg Tab [FMC],2553865,CDM,250,RC,Q0161,HCPCS,OUTPATIENT,1,EA,31.07,18.642,,26.41,85,,21.128,Percent of total billed charges,85% of total billed charges,2.79,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.79,136.6,,1.608,fee schedule,136.60% of BCBS custom fee schedule,10.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,63.9,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.81,38,,9.448,percent of total billed charges,38% of total billed charges,9.93,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,2.79,63.9,
chlorproMAZINE 25 mg Tab [FMC],2553865,CDM,250,RC,Q0161,HCPCS,OUTPATIENT,1,EA,24.32,14.592,,20.67,85,,16.536,Percent of total billed charges,85% of total billed charges,2.79,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.79,136.6,,5.904,fee schedule,136.60% of BCBS custom fee schedule,8.55,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,3.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.24,38,,7.392,percent of total billed charges,38% of total billed charges,7.77,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,2.79,20.67,
chlordiazePOXIDE 5 mg Cap [FMC],2553907,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,11.448,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.392,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
chlordiazePOXIDE 5 mg Cap [FMC],2553907,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,12.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.736,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
chlorthalidone 25 mg Tab [FMC],2553931,CDM,250,RC,,,OUTPATIENT,1,EA,7.46,4.476,,6.34,85,,5.072,Percent of total billed charges,85% of total billed charges,3.73,50,,18.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.73,50,,2.776,percent of total billed charges,50% of total billed charges,2.38,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.38,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.83,38,,2.264,percent of total billed charges,38% of total billed charges,2.98,40,,0.96,percent of total billed charges,40% of total billed charges,2.38,6.34,
chlorthalidone 25 mg Tab [FMC],2553931,CDM,250,RC,,,OUTPATIENT,1,EA,7.46,4.476,,6.34,85,,5.072,Percent of total billed charges,85% of total billed charges,3.73,50,,18.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.73,50,,2.776,percent of total billed charges,50% of total billed charges,2.38,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.38,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.83,38,,2.264,percent of total billed charges,38% of total billed charges,2.98,40,,0.96,percent of total billed charges,40% of total billed charges,2.38,6.34,
phenol Top 1.4% Spry [FMC],2553949,CDM,250,RC,,,OUTPATIENT,180,UN,9.54,5.724,,8.11,85,,6.488,Percent of total billed charges,85% of total billed charges,4.77,50,,18.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.77,50,,1.2,percent of total billed charges,50% of total billed charges,3.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.63,38,,2.904,percent of total billed charges,38% of total billed charges,3.82,40,,0.96,percent of total billed charges,40% of total billed charges,3.05,8.11,
phenol Top 1.4% Spry [FMC],2553949,CDM,250,RC,,,OUTPATIENT,180,UN,23.94,14.364,,20.35,85,,16.28,Percent of total billed charges,85% of total billed charges,11.97,50,,18.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.97,50,,221.328,percent of total billed charges,50% of total billed charges,7.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.1,38,,7.28,percent of total billed charges,38% of total billed charges,9.58,40,,0.96,percent of total billed charges,40% of total billed charges,7.65,20.35,
cholestyramine 4 g/9 g REC UD [FMC],2553972,CDM,250,RC,,,OUTPATIENT,1,EA,10.95,6.57,,9.31,85,,7.448,Percent of total billed charges,85% of total billed charges,5.48,50,,18.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.48,50,,87.736,percent of total billed charges,50% of total billed charges,3.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.16,38,,3.328,percent of total billed charges,38% of total billed charges,4.38,40,,0.96,percent of total billed charges,40% of total billed charges,3.5,9.31,
cholestyramine 4 g/9 g REC UD [FMC],2553972,CDM,250,RC,,,OUTPATIENT,1,EA,10.95,6.57,,9.31,85,,7.448,Percent of total billed charges,85% of total billed charges,5.48,50,,18.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.48,50,,159.384,percent of total billed charges,50% of total billed charges,3.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.16,38,,3.328,percent of total billed charges,38% of total billed charges,4.38,40,,0.96,percent of total billed charges,40% of total billed charges,3.5,9.31,
ciprofloxacin Ophth 0.3% Topical Sol [FMC],2553980,CDM,250,RC,,,OUTPATIENT,5,EA,153.76,92.256,,130.7,85,,104.56,Percent of total billed charges,85% of total billed charges,76.88,50,,18.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,76.88,50,,159.384,percent of total billed charges,50% of total billed charges,49.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,49.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,58.43,38,,46.744,percent of total billed charges,38% of total billed charges,61.5,40,,0.96,percent of total billed charges,40% of total billed charges,49.13,130.7,
ciprofloxacin Ophth 0.3% Topical Sol [FMC],2553980,CDM,250,RC,,,OUTPATIENT,5,EA,33.15,19.89,,28.18,85,,22.544,Percent of total billed charges,85% of total billed charges,16.58,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.58,50,,3.464,percent of total billed charges,50% of total billed charges,10.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,10.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.6,38,,10.08,percent of total billed charges,38% of total billed charges,13.26,40,,0.96,percent of total billed charges,40% of total billed charges,10.59,28.18,
ciprofloxacin Ophth 0.3% Topical Sol [FMC],2553980,CDM,250,RC,,,OUTPATIENT,5,EA,444.91,266.946,,378.17,85,,302.536,Percent of total billed charges,85% of total billed charges,222.46,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,222.46,50,,1.2,percent of total billed charges,50% of total billed charges,142.15,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,142.15,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,169.07,38,,135.256,percent of total billed charges,38% of total billed charges,177.96,40,,1.28,percent of total billed charges,40% of total billed charges,142.15,378.17,
ciprofloxacin Ophth 0.3% Topical Sol [FMC],2553980,CDM,250,RC,,,OUTPATIENT,5,EA,54.6,32.76,,46.41,85,,37.128,Percent of total billed charges,85% of total billed charges,27.3,50,,1.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.3,50,,1.2,percent of total billed charges,50% of total billed charges,17.44,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,17.44,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.75,38,,16.6,percent of total billed charges,38% of total billed charges,21.84,40,,1.28,percent of total billed charges,40% of total billed charges,17.44,46.41,
cimetidine 200 mg Tab [FMC],2554012,CDM,250,RC,,,OUTPATIENT,1,EA,4.17,2.502,,3.54,85,,2.832,Percent of total billed charges,85% of total billed charges,2.09,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.09,50,,3.36,percent of total billed charges,50% of total billed charges,1.33,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.33,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.58,38,,1.264,percent of total billed charges,38% of total billed charges,1.67,40,,1.28,percent of total billed charges,40% of total billed charges,1.33,3.54,
cimetidine 200 mg Tab [FMC],2554012,CDM,250,RC,,,OUTPATIENT,1,EA,4.17,2.502,,3.54,85,,2.832,Percent of total billed charges,85% of total billed charges,2.09,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.09,50,,1.2,percent of total billed charges,50% of total billed charges,1.33,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.33,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.58,38,,1.264,percent of total billed charges,38% of total billed charges,1.67,40,,1.28,percent of total billed charges,40% of total billed charges,1.33,3.54,
ciprofloxacin 400 mg/200 mL IV Sol [FMC],2554079,CDM,250,RC,J0744,HCPCS,OUTPATIENT,200,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.75,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.75,136.6,,3.608,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2.75,30.6,
ciprofloxacin 400 mg/200 mL IV Sol [FMC],2554079,CDM,250,RC,J0744,HCPCS,OUTPATIENT,200,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.75,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2.75,30.6,
ciprofloxacin 400 mg/200 mL IV Sol [FMC],2554079,CDM,250,RC,J0744,HCPCS,OUTPATIENT,200,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.75,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2.75,30.6,
ciprofloxacin 400 mg/200 mL IV Sol [FMC],2554079,CDM,250,RC,J0744,HCPCS,OUTPATIENT,200,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.75,136.6,,6.304,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.75,136.6,,1.264,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,2.75,30.6,
ciprofloxacin 400 mg/200 mL IV Sol [FMC],2554079,CDM,250,RC,J0744,HCPCS,OUTPATIENT,200,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.75,136.6,,1.68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,2.75,30.6,
ciprofloxacin 500 mg Tab [FMC],2554087,CDM,250,RC,,,OUTPATIENT,1,EA,10.33,6.198,,8.78,85,,7.024,Percent of total billed charges,85% of total billed charges,5.17,50,,6.072,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.17,50,,1.576,percent of total billed charges,50% of total billed charges,3.3,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.3,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.93,38,,3.144,percent of total billed charges,38% of total billed charges,4.13,40,,0.96,percent of total billed charges,40% of total billed charges,3.3,8.78,
ciprofloxacin 500 mg Tab [FMC],2554087,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.504,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
ciprofloxacin 500 mg Tab [FMC],2554087,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,54.464,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,49.504,percent of total billed charges,40% of total billed charges,0.96,2.55,
ciprofloxacin 500 mg Tab [FMC],2554087,CDM,250,RC,,,OUTPATIENT,1,EA,17.44,10.464,,14.82,85,,11.856,Percent of total billed charges,85% of total billed charges,8.72,50,,1.992,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.72,50,,1.392,percent of total billed charges,50% of total billed charges,5.57,31.95,,68.544,percent of total billed charges,31.95% of total billed charges,5.57,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.63,38,,5.304,percent of total billed charges,38% of total billed charges,6.98,40,,62.304,percent of total billed charges,40% of total billed charges,5.57,14.82,
loratadine 10 mg Tab [FMC],2554210,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.392,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.168,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,8.976,percent of total billed charges,40% of total billed charges,0.96,2.55,
loratadine 10 mg Tab [FMC],2554210,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.392,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.264,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,11.6,percent of total billed charges,40% of total billed charges,0.96,2.55,
loratadine 10 mg Tab [FMC],2554210,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.784,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.984,percent of total billed charges,40% of total billed charges,0.96,2.55,
loratadine 10 mg Tab [FMC],2554210,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.592,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.008,percent of total billed charges,40% of total billed charges,0.96,2.55,
loratadine-pseudoePHEDrine 5 mg-120 mg ER Tab [FMC],2554251,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.416,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.312,percent of total billed charges,40% of total billed charges,1.28,3.4,
loratadine-pseudoePHEDrine 5 mg-120 mg ER Tab [FMC],2554251,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,12.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.392,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.288,percent of total billed charges,40% of total billed charges,1.28,3.4,
loratadine-pseudoePHEDrine 5 mg-120 mg ER Tab [FMC],2554251,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,13.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.936,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,4.72,percent of total billed charges,40% of total billed charges,1.28,3.4,
loratadine-pseudoePHEDrine 5 mg-120 mg ER Tab [FMC],2554251,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,12.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,2.8,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.512,percent of total billed charges,40% of total billed charges,1.28,3.4,
clindamycin 150 mg/mL IV Sol 6mL  [FMC],2554319,CDM,250,RC,J0736,HCPCS,OUTPATIENT,6,ML,43.16,25.896,,36.69,85,,29.352,Percent of total billed charges,85% of total billed charges,3.03,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.03,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,15.17,35.15,,1.744,percent of total billed charges,35.15% of total billed charges,102.24,31.95,,1.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.4,38,,13.12,percent of total billed charges,38% of total billed charges,13.79,31.95,,2.184,percent of total billed charges,31.95% of total billed charges,3.03,102.24,
clindamycin 150 mg/mL IV Sol 4 mL  [FMC],2554319,CDM,250,RC,J0736,HCPCS,OUTPATIENT,6,ML,17.22,10.332,,14.64,85,,11.712,Percent of total billed charges,85% of total billed charges,3.03,136.6,,7.192,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.03,136.6,,1.848,fee schedule,136.60% of BCBS custom fee schedule,6.05,35.15,,1.776,percent of total billed charges,35.15% of total billed charges,3.02,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.54,38,,5.232,percent of total billed charges,38% of total billed charges,5.5,31.95,,2.224,percent of total billed charges,31.95% of total billed charges,3.02,14.64,
estradiol 0.05 mg/24 hours twice weekly Transderm ER Film [FMC],2554327,CDM,250,RC,,,OUTPATIENT,1,EA,34.08,20.448,,28.97,85,,23.176,Percent of total billed charges,85% of total billed charges,17.04,50,,37.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.04,50,,1.392,percent of total billed charges,50% of total billed charges,10.89,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,10.89,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.95,38,,10.36,percent of total billed charges,38% of total billed charges,13.63,40,,2.224,percent of total billed charges,40% of total billed charges,10.89,28.97,
estradiol 0.05 mg/24 hours twice weekly Transderm ER Film [FMC],2554327,CDM,250,RC,,,OUTPATIENT,1,EA,44.18,26.508,,37.55,85,,30.04,Percent of total billed charges,85% of total billed charges,22.09,50,,80.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.09,50,,1.2,percent of total billed charges,50% of total billed charges,14.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.79,38,,13.432,percent of total billed charges,38% of total billed charges,17.67,40,,0.96,percent of total billed charges,40% of total billed charges,14.12,37.55,
estradiol 0.05 mg/24 hours twice weekly Transderm ER Film [FMC],2554327,CDM,250,RC,,,OUTPATIENT,1,EA,58.51,35.106,,49.73,85,,39.784,Percent of total billed charges,85% of total billed charges,29.26,50,,102.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.26,50,,1.2,percent of total billed charges,50% of total billed charges,18.69,31.95,,141.424,percent of total billed charges,31.95% of total billed charges,18.69,31.95,,141.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.23,38,,17.784,percent of total billed charges,38% of total billed charges,23.4,40,,177.056,percent of total billed charges,40% of total billed charges,18.69,49.73,
clindamycin 150 mg Cap [FMC],2554350,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,102.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,56.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,56.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,70.192,percent of total billed charges,40% of total billed charges,0.96,2.55,
clindamycin 150 mg Cap [FMC],2554350,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,102.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,101.84,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,101.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,127.504,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.1 mg Tab [FMC],2554400,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,27.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.528,percent of total billed charges,50% of total billed charges,0.96,31.95,,101.84,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,101.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,127.504,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.1 mg Tab [FMC],2554400,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,27.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.768,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.1 mg Tab [FMC],2554400,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,27.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.1 mg Tab [FMC],2554400,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,50.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.1 mg Tab [FMC],2554400,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,50.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.144,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.688,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.2 mg Tab [FMC],2554418,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,34.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.264,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.2 mg Tab [FMC],2554418,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,77.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.888,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.2 mg Tab [FMC],2554418,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,77.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.296,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.2 mg Tab [FMC],2554418,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,60.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.2 mg Tab [FMC],2554418,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,78.136,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.992,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.264,percent of total billed charges,40% of total billed charges,0.96,2.55,
cloNIDine 0.2 mg Tab [FMC],2554418,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.416,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.576,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.888,percent of total billed charges,40% of total billed charges,0.96,2.55,
clonazePAM 0.5 mg Tab [FMC],2554434,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,9.608,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.528,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.208,percent of total billed charges,40% of total billed charges,1.28,3.4,
clonazePAM 0.5 mg Tab [FMC],2554434,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.384,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.728,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.392,percent of total billed charges,40% of total billed charges,1.28,3.4,
clonazePAM 0.5 mg Tab [FMC],2554434,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,2.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.416,percent of total billed charges,50% of total billed charges,1.28,31.95,,4.064,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.696,percent of total billed charges,40% of total billed charges,1.28,3.4,
clonazePAM 0.5 mg Tab [FMC],2554434,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,24.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,17.368,percent of total billed charges,50% of total billed charges,1.28,31.95,,4.064,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.696,percent of total billed charges,40% of total billed charges,1.28,3.4,
clonazePAM 0.5 mg Tab [FMC],2554434,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,23.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,20.672,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.008,percent of total billed charges,40% of total billed charges,1.28,3.4,
clonazePAM 0.5 mg Tab [FMC],2554434,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,47.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,17.76,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
clonazePAM 0.5 mg Tab [FMC],2554434,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,24.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,23.792,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.256,percent of total billed charges,40% of total billed charges,1.28,3.4,
hyoscyamine 0.125 mg Oral SL Tab [FMC],2554475,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
hyoscyamine 0.125 mg Oral SL Tab [FMC],2554475,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
hyoscyamine 0.125 mg Oral SL Tab [FMC],2554475,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.848,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.112,percent of total billed charges,40% of total billed charges,0.96,2.55,
hyoscyamine 0.125 mg Oral SL Tab [FMC],2554475,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.808,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.912,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.112,percent of total billed charges,40% of total billed charges,0.96,2.55,
benztropine 1 mg/mL Inj Sol [FMC],2554517,CDM,250,RC,J0515,HCPCS,OUTPATIENT,2,ML,193.67,116.202,,164.62,85,,131.696,Percent of total billed charges,85% of total billed charges,33.48,136.6,,9.536,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,33.48,136.6,,1.912,fee schedule,136.60% of BCBS custom fee schedule,68.08,35.15,,0.888,percent of total billed charges,35.15% of total billed charges,27.16,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.59,38,,58.872,percent of total billed charges,38% of total billed charges,61.88,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,27.16,164.62,
benztropine 1 mg/mL Sol [FMC],2554517,CDM,250,RC,J0515,HCPCS,OUTPATIENT,2,ML,243.75,146.25,,207.19,85,,165.752,Percent of total billed charges,85% of total billed charges,33.48,136.6,,9.536,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,33.48,136.6,,1.312,fee schedule,136.60% of BCBS custom fee schedule,85.68,35.15,,10.12,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,57.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,92.63,38,,74.104,percent of total billed charges,38% of total billed charges,77.88,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,33.48,207.19,
colchicine 0.6 mg Tab [FMC],2554533,CDM,250,RC,,,OUTPATIENT,1,EA,28.04,16.824,,23.83,85,,19.064,Percent of total billed charges,85% of total billed charges,14.02,50,,9.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.02,50,,1.2,percent of total billed charges,50% of total billed charges,8.96,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,8.96,31.95,,57.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.66,38,,8.528,percent of total billed charges,38% of total billed charges,11.22,40,,9.2,percent of total billed charges,40% of total billed charges,8.96,23.83,
colchicine 0.6 mg Tab [FMC],2554533,CDM,250,RC,,,OUTPATIENT,1,EA,36.24,21.744,,30.8,85,,24.64,Percent of total billed charges,85% of total billed charges,18.12,50,,6.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.12,50,,2.312,percent of total billed charges,50% of total billed charges,11.58,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,11.58,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.77,38,,11.016,percent of total billed charges,38% of total billed charges,14.5,40,,11.52,percent of total billed charges,40% of total billed charges,11.58,30.8,
colchicine 0.6 mg Tab [FMC],2554533,CDM,250,RC,,,OUTPATIENT,1,EA,18.71,11.226,,15.9,85,,12.72,Percent of total billed charges,85% of total billed charges,9.36,50,,6.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.36,50,,1.88,percent of total billed charges,50% of total billed charges,5.98,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,5.98,31.95,,77.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.11,38,,5.688,percent of total billed charges,38% of total billed charges,7.48,40,,9.2,percent of total billed charges,40% of total billed charges,5.98,15.9,
colchicine 0.6 mg Tab [FMC],2554533,CDM,250,RC,,,OUTPATIENT,1,EA,21.89,13.134,,18.61,85,,14.888,Percent of total billed charges,85% of total billed charges,10.95,50,,5.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.95,50,,1.488,percent of total billed charges,50% of total billed charges,6.99,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,6.99,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.32,38,,6.656,percent of total billed charges,38% of total billed charges,8.76,40,,11.52,percent of total billed charges,40% of total billed charges,6.99,18.61,
colestipol 1 g Tab [FMC],2554541,CDM,250,RC,,,OUTPATIENT,1,EA,4.1,2.46,,3.49,85,,2.792,Percent of total billed charges,85% of total billed charges,2.05,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.05,50,,1.2,percent of total billed charges,50% of total billed charges,1.31,31.95,,11.808,percent of total billed charges,31.95% of total billed charges,1.31,31.95,,77.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.56,38,,1.248,percent of total billed charges,38% of total billed charges,1.64,40,,10.736,percent of total billed charges,40% of total billed charges,1.31,3.49,
colestipol 1 g Tab [FMC],2554541,CDM,250,RC,,,OUTPATIENT,1,EA,4.02,2.412,,3.42,85,,2.736,Percent of total billed charges,85% of total billed charges,2.01,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.01,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,2.824,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.53,38,,1.224,percent of total billed charges,38% of total billed charges,1.61,40,,3.536,percent of total billed charges,40% of total billed charges,1.28,3.42,
entacapone 200 mg Tab[FMC],2554590,CDM,250,RC,,,OUTPATIENT,1,EA,14.75,8.85,,12.54,85,,10.032,Percent of total billed charges,85% of total billed charges,7.38,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.38,50,,1.2,percent of total billed charges,50% of total billed charges,4.71,31.95,,2.8,percent of total billed charges,31.95% of total billed charges,4.71,31.95,,2.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.61,38,,4.488,percent of total billed charges,38% of total billed charges,5.9,40,,3.512,percent of total billed charges,40% of total billed charges,4.71,12.54,
entacapone 200 mg Tab[FMC],2554590,CDM,250,RC,,,OUTPATIENT,1,EA,10.97,6.582,,9.32,85,,7.456,Percent of total billed charges,85% of total billed charges,5.49,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.49,50,,11.448,percent of total billed charges,50% of total billed charges,3.5,31.95,,3.792,percent of total billed charges,31.95% of total billed charges,3.5,31.95,,3.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.17,38,,3.336,percent of total billed charges,38% of total billed charges,4.39,40,,4.752,percent of total billed charges,40% of total billed charges,3.5,9.32,
carvedilol 3.125 mg Tab [FMC],2554665,CDM,250,RC,,,OUTPATIENT,1,EA,6.83,4.098,,5.81,85,,4.648,Percent of total billed charges,85% of total billed charges,3.42,50,,2.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.42,50,,12.624,percent of total billed charges,50% of total billed charges,2.18,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.18,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.6,38,,2.08,percent of total billed charges,38% of total billed charges,2.73,40,,0.96,percent of total billed charges,40% of total billed charges,2.18,5.81,
carvedilol 3.125 mg Tab [FMC],2554665,CDM,250,RC,,,OUTPATIENT,1,EA,6.94,4.164,,5.9,85,,4.72,Percent of total billed charges,85% of total billed charges,3.47,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,18.112,percent of total billed charges,50% of total billed charges,2.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.64,38,,2.112,percent of total billed charges,38% of total billed charges,2.78,40,,0.96,percent of total billed charges,40% of total billed charges,2.22,5.9,
carvedilol 3.125 mg Tab [FMC],2554665,CDM,250,RC,,,OUTPATIENT,1,EA,6.94,4.164,,5.9,85,,4.72,Percent of total billed charges,85% of total billed charges,3.47,50,,2.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,18.216,percent of total billed charges,50% of total billed charges,2.22,31.95,,1.176,percent of total billed charges,31.95% of total billed charges,2.22,31.95,,1.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.64,38,,2.112,percent of total billed charges,38% of total billed charges,2.78,40,,1.472,percent of total billed charges,40% of total billed charges,2.22,5.9,
carvedilol 3.125 mg Tab [FMC],2554665,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,18.112,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.112,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrocortisone/neomycin/polymyxin B Ophth 10 mg- 3.5 mg- 10000 units per mL Susp [FMC],2554731,CDM,250,RC,,,OUTPATIENT,7.5,EA,553.31,331.986,,470.31,85,,376.248,Percent of total billed charges,85% of total billed charges,276.66,50,,2.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,276.66,50,,18.112,percent of total billed charges,50% of total billed charges,176.78,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,176.78,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,210.26,38,,168.208,percent of total billed charges,38% of total billed charges,221.32,40,,0.96,percent of total billed charges,40% of total billed charges,176.78,470.31,
dorzolamide-timolol ophthalmic 2.23%-0.68% Sol [FMC],2554756,CDM,250,RC,,,OUTPATIENT,10,EA,219.34,131.604,,186.44,85,,149.152,Percent of total billed charges,85% of total billed charges,109.67,50,,2.848,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,109.67,50,,18.216,percent of total billed charges,50% of total billed charges,70.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,70.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,83.35,38,,66.68,percent of total billed charges,38% of total billed charges,87.74,40,,0.96,percent of total billed charges,40% of total billed charges,70.08,186.44,
dorzolamide-timolol ophthalmic 2.23%-0.68% Sol [FMC],2554756,CDM,250,RC,,,OUTPATIENT,10,EA,398.45,239.07,,338.68,85,,270.944,Percent of total billed charges,85% of total billed charges,199.23,50,,1.344,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,199.23,50,,18.112,percent of total billed charges,50% of total billed charges,127.3,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,127.3,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,151.41,38,,121.128,percent of total billed charges,38% of total billed charges,159.38,40,,0.96,percent of total billed charges,40% of total billed charges,127.3,338.68,
dorzolamide-timolol ophthalmic 2.23%-0.68% Sol [FMC],2554756,CDM,250,RC,,,OUTPATIENT,10,EA,398.45,239.07,,338.68,85,,270.944,Percent of total billed charges,85% of total billed charges,199.23,50,,1.512,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,199.23,50,,18.112,percent of total billed charges,50% of total billed charges,127.3,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,127.3,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,151.41,38,,121.128,percent of total billed charges,38% of total billed charges,159.38,40,,0.96,percent of total billed charges,40% of total billed charges,127.3,338.68,
warfarin 2.5 mg Tab [FMC],2554798,CDM,250,RC,,,OUTPATIENT,1,EA,8.66,5.196,,7.36,85,,5.888,Percent of total billed charges,85% of total billed charges,4.33,50,,109.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.33,50,,1.2,percent of total billed charges,50% of total billed charges,2.77,31.95,,1.616,percent of total billed charges,31.95% of total billed charges,2.77,31.95,,1.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.29,38,,2.632,percent of total billed charges,38% of total billed charges,3.46,40,,2.024,percent of total billed charges,40% of total billed charges,2.77,7.36,
warfarin 2.5 mg Tab [FMC],2554798,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
warfarin 2 mg Tab [FMC],2554806,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.624,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
warfarin 2 mg Tab [FMC],2554806,CDM,250,RC,,,OUTPATIENT,1,EA,8.39,5.034,,7.13,85,,5.704,Percent of total billed charges,85% of total billed charges,4.2,50,,118.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.2,50,,1.2,percent of total billed charges,50% of total billed charges,2.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.19,38,,2.552,percent of total billed charges,38% of total billed charges,3.36,40,,0.96,percent of total billed charges,40% of total billed charges,2.68,7.13,
warfarin 2 mg Tab [FMC],2554806,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
warfarin 5 mg Tab [FMC],2554822,CDM,250,RC,,,OUTPATIENT,1,EA,9.02,5.412,,7.67,85,,6.136,Percent of total billed charges,85% of total billed charges,4.51,50,,3.344,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.51,50,,1.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,1.448,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,1.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.43,38,,2.744,percent of total billed charges,38% of total billed charges,3.61,40,,1.808,percent of total billed charges,40% of total billed charges,2.88,7.67,
warfarin 5 mg Tab [FMC],2554822,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.896,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.12,percent of total billed charges,40% of total billed charges,0.96,2.55,
warfarin 5 mg Tab [FMC],2554822,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.464,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.832,percent of total billed charges,40% of total billed charges,0.96,2.55,
CyanocobaLamine SD 1000MCG/ML [FMC],2554913,CDM,250,RC,J3420,HCPCS,OUTPATIENT,1,ML,28.41,17.046,,24.15,85,,19.32,Percent of total billed charges,85% of total billed charges,1.99,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.99,136.6,,1.304,fee schedule,136.60% of BCBS custom fee schedule,9.99,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.8,38,,8.64,percent of total billed charges,38% of total billed charges,9.08,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.99,95.85,
CyanocobaLamine SD 1000MCG/ML [FMC],2554913,CDM,250,RC,J3420,HCPCS,OUTPATIENT,1,ML,26.95,16.17,,22.91,85,,18.328,Percent of total billed charges,85% of total billed charges,1.99,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.99,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,9.47,35.15,,10.824,percent of total billed charges,35.15% of total billed charges,3.02,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.24,38,,8.192,percent of total billed charges,38% of total billed charges,8.61,31.95,,9.84,percent of total billed charges,31.95% of total billed charges,1.99,22.91,
CyanocobaLamine SD 1000MCG/ML [FMC],2554913,CDM,250,RC,J3420,HCPCS,OUTPATIENT,1,ML,12.56,7.536,,10.68,85,,8.544,Percent of total billed charges,85% of total billed charges,1.99,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.99,136.6,,6.304,fee schedule,136.60% of BCBS custom fee schedule,4.41,35.15,,12.472,percent of total billed charges,35.15% of total billed charges,3.02,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.77,38,,3.816,percent of total billed charges,38% of total billed charges,4.01,31.95,,11.336,percent of total billed charges,31.95% of total billed charges,1.99,10.68,
CyanocobaLamine SD 1000MCG/ML [FMC],2554913,CDM,250,RC,J3420,HCPCS,OUTPATIENT,1,ML,13.26,7.956,,11.27,85,,9.016,Percent of total billed charges,85% of total billed charges,1.99,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.99,136.6,,6.048,fee schedule,136.60% of BCBS custom fee schedule,4.66,35.15,,10.056,percent of total billed charges,35.15% of total billed charges,2.88,31.95,,131.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.04,38,,4.032,percent of total billed charges,38% of total billed charges,4.24,31.95,,9.144,percent of total billed charges,31.95% of total billed charges,1.99,11.27,
CyanocobaLamine SD 1000MCG/ML [FMC],2554913,CDM,250,RC,J3420,HCPCS,OUTPATIENT,1,ML,14.46,8.676,,12.29,85,,9.832,Percent of total billed charges,85% of total billed charges,1.99,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.99,136.6,,6.088,fee schedule,136.60% of BCBS custom fee schedule,5.08,35.15,,10.576,percent of total billed charges,35.15% of total billed charges,3.02,31.95,,131.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.49,38,,4.392,percent of total billed charges,38% of total billed charges,4.62,31.95,,9.608,percent of total billed charges,31.95% of total billed charges,1.99,12.29,
CyanocobaLamine SD 1000MCG/ML [FMC],2554913,CDM,250,RC,J3420,HCPCS,OUTPATIENT,1,ML,14.46,8.676,,12.29,85,,9.832,Percent of total billed charges,85% of total billed charges,1.99,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.99,136.6,,6.048,fee schedule,136.60% of BCBS custom fee schedule,5.08,35.15,,66.16,percent of total billed charges,35.15% of total billed charges,156.56,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.49,38,,4.392,percent of total billed charges,38% of total billed charges,4.62,31.95,,60.136,percent of total billed charges,31.95% of total billed charges,1.99,156.56,
cyclobenzaprine 10 mg Tab [FMC],2554939,CDM,250,RC,,,OUTPATIENT,1,EA,3.15,1.89,,2.68,85,,2.144,Percent of total billed charges,85% of total billed charges,1.58,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.58,50,,6.304,percent of total billed charges,50% of total billed charges,1.01,31.95,,76.784,percent of total billed charges,31.95% of total billed charges,1.01,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.2,38,,0.96,percent of total billed charges,38% of total billed charges,1.26,40,,69.8,percent of total billed charges,40% of total billed charges,1.01,2.68,
cyclobenzaprine 10 mg Tab [FMC],2554939,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,41.656,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.68,percent of total billed charges,50% of total billed charges,0.96,31.95,,64.48,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,58.608,percent of total billed charges,40% of total billed charges,0.96,2.55,
cyclobenzaprine 10 mg Tab [FMC],2554939,CDM,250,RC,,,OUTPATIENT,1,EA,3.93,2.358,,3.34,85,,2.672,Percent of total billed charges,85% of total billed charges,1.97,50,,76.728,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.97,50,,6.072,percent of total billed charges,50% of total billed charges,1.26,31.95,,49.928,percent of total billed charges,31.95% of total billed charges,1.26,31.95,,49.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.49,38,,1.192,percent of total billed charges,38% of total billed charges,1.57,40,,62.504,percent of total billed charges,40% of total billed charges,1.26,3.34,
cyclobenzaprine 10 mg Tab [FMC],2554939,CDM,250,RC,,,OUTPATIENT,1,EA,3.76,2.256,,3.2,85,,2.56,Percent of total billed charges,85% of total billed charges,1.88,50,,26.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.88,50,,5.56,percent of total billed charges,50% of total billed charges,1.2,31.95,,2.824,percent of total billed charges,31.95% of total billed charges,1.2,31.95,,2.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.43,38,,1.144,percent of total billed charges,38% of total billed charges,1.5,40,,3.536,percent of total billed charges,40% of total billed charges,1.2,3.2,
cyclobenzaprine 10 mg Tab [FMC],2554939,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,47.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.064,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.688,percent of total billed charges,40% of total billed charges,0.96,2.55,
cyproheptadine 4 mg Tab [FMC],2554988,CDM,250,RC,,,OUTPATIENT,1,EA,3.47,2.082,,2.95,85,,2.36,Percent of total billed charges,85% of total billed charges,1.74,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.74,50,,1.992,percent of total billed charges,50% of total billed charges,1.11,31.95,,1.52,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,1.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.32,38,,1.056,percent of total billed charges,38% of total billed charges,1.39,40,,1.904,percent of total billed charges,40% of total billed charges,1.11,2.95,
cyproheptadine 4 mg Tab [FMC],2554988,CDM,250,RC,,,OUTPATIENT,1,EA,3.47,2.082,,2.95,85,,2.36,Percent of total billed charges,85% of total billed charges,1.74,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.74,50,,2.976,percent of total billed charges,50% of total billed charges,1.11,31.95,,2.824,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,2.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.32,38,,1.056,percent of total billed charges,38% of total billed charges,1.39,40,,3.536,percent of total billed charges,40% of total billed charges,1.11,2.95,
cyproheptadine 4 mg Tab [FMC],2554988,CDM,250,RC,,,OUTPATIENT,1,EA,3.47,2.082,,2.95,85,,2.36,Percent of total billed charges,85% of total billed charges,1.74,50,,3.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.74,50,,2.976,percent of total billed charges,50% of total billed charges,1.11,31.95,,16.016,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.32,38,,1.056,percent of total billed charges,38% of total billed charges,1.39,40,,14.56,percent of total billed charges,40% of total billed charges,1.11,2.95,
Dextrose 5% in Water IV Sol 1000 mL [FMC],2555035,CDM,250,RC,J7070,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.9,136.6,,7.728,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.9,136.6,,3.72,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,17.656,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,42.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,16.048,Fee Schedule,31.95% of LA custom fee schedule,4.9,30.6,
Dextrose 5% in Water IV Sol 1000 mL [FMC],2555035,CDM,250,RC,J7070,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.9,136.6,,11.576,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.9,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,11.096,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,11.096,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,13.896,Fee Schedule,31.95% of LA custom fee schedule,4.9,30.6,
Dextrose 5% in water and 0.2% Sodium Chloride IV Sol 1000 mL [FMC],2555043,CDM,250,RC,J7042,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.76,136.6,,2.664,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,13.208,percent of total billed charges,35.15% of total billed charges,71.89,31.95,,13.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,16.536,percent of total billed charges,31.95% of total billed charges,1.76,71.89,
Dextrose 5% in water and 0.2% Sodium Chloride IV Sol 1000 mL [FMC,2555043,CDM,250,RC,J7042,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.76,136.6,,7.728,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,11.352,percent of total billed charges,35.15% of total billed charges,71.89,31.95,,11.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,14.208,percent of total billed charges,31.95% of total billed charges,1.76,71.89,
Sodium Chloride 0.45% IV Sol 500 mL [FMC],2555050,CDM,250,RC,,,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,13.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,1.2,percent of total billed charges,50% of total billed charges,11.5,31.95,,15.2,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,15.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,19.032,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [FMC],2555068,CDM,250,RC,S5010,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,7.51,136.6,,2.432,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.51,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,96.81,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,7.51,96.81,
Dextrose 5% in Water IV Sol 250 mL [FMC],2555100,CDM,250,RC,J7060,HCPCS,OUTPATIENT,250,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.45,136.6,,6.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.45,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2.45,30.6,
Dextrose 5% in Water IV Sol 250 mL [FMC],2555100,CDM,250,RC,J7060,HCPCS,OUTPATIENT,250,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.45,136.6,,3.112,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.45,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2.45,30.6,
Dextrose 5% in Water IV Sol 50 mL [FMC],2555118,CDM,250,RC,,,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,55.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,1.2,percent of total billed charges,50% of total billed charges,11.5,31.95,,1.224,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,1.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,1.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% in Water IV Sol 500 mL [FMC],2555126,CDM,250,RC,J7060,HCPCS,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,2.45,136.6,,6.896,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.45,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.224,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,1.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.528,Fee Schedule,31.95% of LA custom fee schedule,2.45,30.6,
Dextrose 5% with 0.9% NaCL Sol 1000ml [FMC],2555142,CDM,250,RC,J7042,HCPCS,OUTPATIENT,1000,ML,41.99,25.194,,35.69,85,,28.552,Percent of total billed charges,85% of total billed charges,1.76,136.6,,28.216,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.76,136.6,,1.736,fee schedule,136.60% of BCBS custom fee schedule,14.76,35.15,,0.84,percent of total billed charges,35.15% of total billed charges,96.81,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,12.768,percent of total billed charges,38% of total billed charges,13.42,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,1.76,96.81,
"Ophth irrigation, extraocular Sol [FMC]",2555167,CDM,250,RC,,,OUTPATIENT,120,EA,11.04,6.624,,9.38,85,,7.504,Percent of total billed charges,85% of total billed charges,5.52,50,,11.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.52,50,,1.2,percent of total billed charges,50% of total billed charges,3.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.2,38,,3.36,percent of total billed charges,38% of total billed charges,4.42,40,,0.96,percent of total billed charges,40% of total billed charges,3.53,9.38,
"Ophth irrigation, extraocular Sol [FMC]",2555167,CDM,250,RC,,,OUTPATIENT,120,EA,10.97,6.582,,9.32,85,,7.456,Percent of total billed charges,85% of total billed charges,5.49,50,,25.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.49,50,,12.264,percent of total billed charges,50% of total billed charges,3.5,31.95,,1.472,percent of total billed charges,31.95% of total billed charges,3.5,31.95,,1.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.17,38,,3.336,percent of total billed charges,38% of total billed charges,4.39,40,,1.848,percent of total billed charges,40% of total billed charges,3.5,9.32,
"Ophth irrigation, extraocular Sol [FMC]",2555167,CDM,250,RC,,,OUTPATIENT,120,EA,14.84,8.904,,12.61,85,,10.088,Percent of total billed charges,85% of total billed charges,7.42,50,,4.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.42,50,,13.496,percent of total billed charges,50% of total billed charges,4.74,31.95,,1.2,percent of total billed charges,31.95% of total billed charges,4.74,31.95,,1.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.64,38,,4.512,percent of total billed charges,38% of total billed charges,5.94,40,,1.504,percent of total billed charges,40% of total billed charges,4.74,12.61,
torsemide 20 mg Tab [FMC],2555316,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12.128,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.952,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.184,percent of total billed charges,40% of total billed charges,0.96,2.55,
torsemide 20 mg Tab [FMC],2555316,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
meperidine 50 mg/mL Inj Sol [FMC],2555332,CDM,250,RC,J2175,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,10.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.15,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,4.47,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,4.47,11.9,
meperidine 50 mg/mL Inj Sol [FMC],2555332,CDM,250,RC,J2175,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,10.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.15,136.6,,5.344,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,4.47,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,4.47,11.9,
meperidine 50 mg/mL Inj Sol [FMC],2555332,CDM,250,RC,J2175,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,10.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.15,136.6,,3.192,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,7.312,fee schedule,35.15% of LA custom fee schedule,4.47,31.95,,7.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,9.152,Fee Schedule,31.95% of LA custom fee schedule,4.47,11.9,
divalproex sodium 125 mg Oral DR sprinkles Cap [FMC],2555357,CDM,250,RC,,,OUTPATIENT,1,EA,4.61,2.766,,3.92,85,,3.136,Percent of total billed charges,85% of total billed charges,2.31,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.31,50,,7.192,percent of total billed charges,50% of total billed charges,1.47,31.95,,8.064,percent of total billed charges,31.95% of total billed charges,1.47,31.95,,8.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.75,38,,1.4,percent of total billed charges,38% of total billed charges,1.84,40,,10.096,percent of total billed charges,40% of total billed charges,1.47,3.92,
divalproex sodium 125 mg Oral DR sprinkles Cap [FMC],2555357,CDM,250,RC,,,OUTPATIENT,1,EA,3.48,2.088,,2.96,85,,2.368,Percent of total billed charges,85% of total billed charges,1.74,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.74,50,,37.096,percent of total billed charges,50% of total billed charges,1.11,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.32,38,,1.056,percent of total billed charges,38% of total billed charges,1.39,40,,14.488,percent of total billed charges,40% of total billed charges,1.11,2.96,
divalproex sodium 125 mg Oral DR Tab [FMC],2555365,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.744,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,80.216,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.64,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.568,percent of total billed charges,40% of total billed charges,0.96,2.55,
divalproex sodium 125 mg Oral DR Tab [FMC],2555365,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,102.328,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.568,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.488,percent of total billed charges,40% of total billed charges,0.96,2.55,
divalproex sodium 125 mg Oral DR Tab [FMC],2555365,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,102.328,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.488,percent of total billed charges,40% of total billed charges,0.96,2.55,
divalproex sodium 125 mg Oral DR Tab [FMC],2555365,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,102.328,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.64,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
divalproex sodium 250 mg ER Tab [FMC],2555373,CDM,250,RC,,,OUTPATIENT,1,EA,6.32,3.792,,5.37,85,,4.296,Percent of total billed charges,85% of total billed charges,3.16,50,,5.824,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.16,50,,27.648,percent of total billed charges,50% of total billed charges,2.02,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,2.02,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.4,38,,1.92,percent of total billed charges,38% of total billed charges,2.53,40,,14.488,percent of total billed charges,40% of total billed charges,2.02,5.37,
divalproex sodium 250 mg ER Tab [FMC],2555373,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,27.648,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.488,percent of total billed charges,40% of total billed charges,0.96,2.55,
valproic acid 250 mg/5 mL Oral Syrup [FMC],2555381,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,27.648,percent of total billed charges,50% of total billed charges,0.96,31.95,,4849.52,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4408.024,percent of total billed charges,40% of total billed charges,0.96,2.55,
valproic acid 250 mg/5 mL Oral Syrup [FMC],2555381,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,50.552,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.832,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,44.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.208,percent of total billed charges,40% of total billed charges,0.96,2.55,
valproic acid 250 mg/5 mL Oral Syrup [FMC],2555381,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,50.552,percent of total billed charges,50% of total billed charges,0.96,31.95,,126.088,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,44.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,114.608,percent of total billed charges,40% of total billed charges,0.96,2.55,
divalproex sodium 250 mg Oral DR Tab [FMC],2555399,CDM,250,RC,,,OUTPATIENT,1,EA,5.66,3.396,,4.81,85,,3.848,Percent of total billed charges,85% of total billed charges,2.83,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.83,50,,34.272,percent of total billed charges,50% of total billed charges,1.81,31.95,,6.032,percent of total billed charges,31.95% of total billed charges,1.81,31.95,,44.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.15,38,,1.72,percent of total billed charges,38% of total billed charges,2.26,40,,5.48,percent of total billed charges,40% of total billed charges,1.81,4.81,
divalproex sodium 250 mg Oral DR Tab [FMC],2555399,CDM,250,RC,,,OUTPATIENT,1,EA,3.49,2.094,,2.97,85,,2.376,Percent of total billed charges,85% of total billed charges,1.75,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.75,50,,77.096,percent of total billed charges,50% of total billed charges,1.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.33,38,,1.064,percent of total billed charges,38% of total billed charges,1.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.12,2.97,
divalproex sodium 250 mg Oral DR Tab [FMC],2555399,CDM,250,RC,,,OUTPATIENT,1,EA,5.73,3.438,,4.87,85,,3.896,Percent of total billed charges,85% of total billed charges,2.87,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.87,50,,77.104,percent of total billed charges,50% of total billed charges,1.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.18,38,,1.744,percent of total billed charges,38% of total billed charges,2.29,40,,0.96,percent of total billed charges,40% of total billed charges,1.83,4.87,
divalproex sodium 250 mg Oral DR Tab [FMC],2555399,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,60.44,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.296,percent of total billed charges,40% of total billed charges,0.96,2.55,
methylPREDNISolone 40 mg/mL Sus [FMC],2555449,CDM,250,RC,J1010,HCPCS,OUTPATIENT,1,ML,38.49,23.094,,32.72,85,,26.176,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,77.096,fee schedule,136.60% of BCBS custom fee schedule,13.53,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.63,38,,11.704,percent of total billed charges,38% of total billed charges,12.3,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.19,52.72,
methylPREDNISolone 40 mg/mL Sus [FMC],2555449,CDM,250,RC,J1010,HCPCS,OUTPATIENT,1,ML,44.34,26.604,,37.69,85,,30.152,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,52.272,fee schedule,136.60% of BCBS custom fee schedule,15.59,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.85,38,,13.48,percent of total billed charges,38% of total billed charges,14.17,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.19,52.72,
methylPREDNISolone 40 mg/mL Sus [FMC],2555449,CDM,250,RC,J1010,HCPCS,OUTPATIENT,1,ML,35.76,21.456,,30.4,85,,24.32,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,5.416,fee schedule,136.60% of BCBS custom fee schedule,12.57,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,164.22,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.59,38,,10.872,percent of total billed charges,38% of total billed charges,11.43,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.19,164.22,
methylPREDNISolone 40 mg/mL Sus [FMC],2555449,CDM,250,RC,J1010,HCPCS,OUTPATIENT,1,ML,37.6,22.56,,31.96,85,,25.568,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,4.864,fee schedule,136.60% of BCBS custom fee schedule,13.22,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,164.22,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.29,38,,11.432,percent of total billed charges,38% of total billed charges,12.01,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.19,164.22,
desmopressin 4 mcg/mL Sol [FMC],2555530,CDM,250,RC,J2597,HCPCS,OUTPATIENT,1,ML,235.27,141.162,,199.98,85,,159.984,Percent of total billed charges,85% of total billed charges,9.25,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.25,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,82.7,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,89.4,38,,71.52,percent of total billed charges,38% of total billed charges,75.17,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,9.25,199.98,
desmopressin 4 mcg/mL Sol [FMC],2555530,CDM,250,RC,J2597,HCPCS,OUTPATIENT,1,ML,273.07,163.842,,232.11,85,,185.688,Percent of total billed charges,85% of total billed charges,9.25,136.6,,2.304,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.25,136.6,,5.416,fee schedule,136.60% of BCBS custom fee schedule,95.98,35.15,,0.832,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,103.77,38,,83.016,percent of total billed charges,38% of total billed charges,87.25,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,9.25,232.11,
desmopressin 4 mcg/mL Sol [FMC],2555530,CDM,250,RC,J2597,HCPCS,OUTPATIENT,1,ML,229.29,137.574,,194.9,85,,155.92,Percent of total billed charges,85% of total billed charges,9.25,136.6,,1.272,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.25,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,80.6,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,87.13,38,,69.704,percent of total billed charges,38% of total billed charges,73.26,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,9.25,194.9,
desonide topical 0.05% Ointment 15 gm [FMC],2555555,CDM,250,RC,,,OUTPATIENT,15,EA,195.33,117.198,,166.03,85,,132.824,Percent of total billed charges,85% of total billed charges,97.67,50,,1.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,97.67,50,,2.6,percent of total billed charges,50% of total billed charges,62.41,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,62.41,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,74.23,38,,59.384,percent of total billed charges,38% of total billed charges,78.13,40,,5.04,percent of total billed charges,40% of total billed charges,62.41,166.03,
tolterodine 2 mg Tab [FMC],2555613,CDM,250,RC,,,OUTPATIENT,1,EA,11.04,6.624,,9.38,85,,7.504,Percent of total billed charges,85% of total billed charges,5.52,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.52,50,,2.6,percent of total billed charges,50% of total billed charges,3.53,31.95,,3.864,percent of total billed charges,31.95% of total billed charges,3.53,31.95,,3.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.2,38,,3.36,percent of total billed charges,38% of total billed charges,4.42,40,,4.832,percent of total billed charges,40% of total billed charges,3.53,9.38,
tolterodine 2 mg Tab [FMC],2555613,CDM,250,RC,,,OUTPATIENT,1,EA,24.02,14.412,,20.42,85,,16.336,Percent of total billed charges,85% of total billed charges,12.01,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.01,50,,2.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.13,38,,7.304,percent of total billed charges,38% of total billed charges,9.61,40,,4.872,percent of total billed charges,40% of total billed charges,7.67,20.42,
tolterodine 2 mg Tab [FMC],2555613,CDM,250,RC,,,OUTPATIENT,1,EA,5.96,3.576,,5.07,85,,4.056,Percent of total billed charges,85% of total billed charges,2.98,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.98,50,,2.6,percent of total billed charges,50% of total billed charges,1.9,31.95,,3.864,percent of total billed charges,31.95% of total billed charges,1.9,31.95,,3.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.26,38,,1.808,percent of total billed charges,38% of total billed charges,2.38,40,,4.832,percent of total billed charges,40% of total billed charges,1.9,5.07,
tolterodine 2 mg Tab [FMC],2555613,CDM,250,RC,,,OUTPATIENT,1,EA,11.04,6.624,,9.38,85,,7.504,Percent of total billed charges,85% of total billed charges,5.52,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.52,50,,2.112,percent of total billed charges,50% of total billed charges,3.53,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,3.53,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.2,38,,3.36,percent of total billed charges,38% of total billed charges,4.42,40,,5.04,percent of total billed charges,40% of total billed charges,3.53,9.38,
dexamethasone 4 mg/mL Inj Sol [FMC],2555662,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,2.528,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.072,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.072,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.344,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
dexamethasone 4 mg/mL Inj Sol [FMC],2555662,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.88,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,3.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,4.856,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
dexamethasone 4 mg/mL Inj Sol [FMC],2555662,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,8.288,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.552,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,3.552,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,4.448,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
dexamethasone 4 mg/mL Inj Sol [FMC],2555662,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,7.4,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.872,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,3.872,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,4.848,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
dexamethasone 4 mg/mL Inj Sol [FMC],2555662,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,43.984,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,8.288,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,30.704,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,7.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,27.912,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
dexamethasone 4 mg/mL Inj Sol [FMC],2555662,CDM,250,RC,J1100,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.19,136.6,,48.976,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,100.12,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,34.272,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,108.376,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,31.152,Fee Schedule,31.95% of LA custom fee schedule,0.19,10.2,
iron dextran 50 mg/mL Inj Sol [FMC],2555670,CDM,250,RC,J1750,HCPCS,OUTPATIENT,1,ML,56.96,34.176,,48.42,85,,38.736,Percent of total billed charges,85% of total billed charges,26.16,136.6,,51.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.16,136.6,,73.776,fee schedule,136.60% of BCBS custom fee schedule,20.02,35.15,,34.272,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,108.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.64,38,,17.312,percent of total billed charges,38% of total billed charges,18.2,31.95,,31.152,percent of total billed charges,31.95% of total billed charges,18.2,52.72,
iron dextran 50 mg/mL Inj Sol [FMC],2555670,CDM,250,RC,J1750,HCPCS,OUTPATIENT,1,ML,62.8,37.68,,53.38,85,,42.704,Percent of total billed charges,85% of total billed charges,26.16,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.16,136.6,,39.016,fee schedule,136.60% of BCBS custom fee schedule,22.07,35.15,,23.448,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,108.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.86,38,,19.088,percent of total billed charges,38% of total billed charges,20.06,31.95,,21.312,percent of total billed charges,31.95% of total billed charges,20.06,53.38,
glucose 50% Sol [FMC],2555704,CDM,250,RC,,,OUTPATIENT,50,ML,43.42,26.052,,36.91,85,,29.528,Percent of total billed charges,85% of total billed charges,21.71,50,,3.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.71,50,,24.704,percent of total billed charges,50% of total billed charges,13.87,31.95,,30.6,percent of total billed charges,31.95% of total billed charges,13.87,31.95,,108.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.5,38,,13.2,percent of total billed charges,38% of total billed charges,17.37,40,,27.808,percent of total billed charges,40% of total billed charges,13.87,36.91,
glucose 50% Sol [FMC],2555704,CDM,250,RC,,,OUTPATIENT,50,ML,51.68,31.008,,43.93,85,,35.144,Percent of total billed charges,85% of total billed charges,25.84,50,,3.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.84,50,,23.352,percent of total billed charges,50% of total billed charges,16.51,31.95,,23.68,percent of total billed charges,31.95% of total billed charges,16.51,31.95,,108.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.64,38,,15.712,percent of total billed charges,38% of total billed charges,20.67,40,,21.528,percent of total billed charges,40% of total billed charges,16.51,43.93,
glucose 50% Sol [FMC],2555704,CDM,250,RC,,,OUTPATIENT,50,ML,44.4,26.64,,37.74,85,,30.192,Percent of total billed charges,85% of total billed charges,22.2,50,,5.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.2,50,,47.152,percent of total billed charges,50% of total billed charges,14.19,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,14.19,31.95,,108.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.87,38,,13.496,percent of total billed charges,38% of total billed charges,17.76,40,,3.064,percent of total billed charges,40% of total billed charges,14.19,37.74,
glucose 50% Sol [FMC],2555704,CDM,250,RC,,,OUTPATIENT,50,ML,59.48,35.688,,50.56,85,,40.448,Percent of total billed charges,85% of total billed charges,29.74,50,,2.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.74,50,,24.248,percent of total billed charges,50% of total billed charges,19,31.95,,6.584,percent of total billed charges,31.95% of total billed charges,19,31.95,,44.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.6,38,,18.08,percent of total billed charges,38% of total billed charges,23.79,40,,5.984,percent of total billed charges,40% of total billed charges,19,50.56,
diazepam 5 mg/mL Inj Sol [FMC],2555738,CDM,250,RC,J3360,HCPCS,OUTPATIENT,1,ML,54.25,32.55,,46.11,85,,36.888,Percent of total billed charges,85% of total billed charges,11.24,136.6,,5.312,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.24,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,19.07,35.15,,6.088,fee schedule,35.15% of LA custom fee schedule,17.33,31.95,,44.984,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.62,38,,16.496,percent of total billed charges,38% of total billed charges,17.33,31.95,,5.536,Fee Schedule,31.95% of LA custom fee schedule,11.24,46.11,
diazepam 5 mg/mL Inj Sol [FMC],2555738,CDM,250,RC,J3360,HCPCS,OUTPATIENT,1,ML,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,11.24,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.24,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,16.87,35.15,,4.744,fee schedule,35.15% of LA custom fee schedule,15.34,31.95,,44.984,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.24,38,,14.592,percent of total billed charges,38% of total billed charges,15.34,31.95,,4.312,Fee Schedule,31.95% of LA custom fee schedule,11.24,40.8,
diazepam 5 mg Tab [FMC],2555753,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.776,percent of total billed charges,50% of total billed charges,1.28,31.95,,6.376,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,5.792,percent of total billed charges,40% of total billed charges,1.28,3.4,
diazepam 5 mg Tab [FMC],2555753,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.776,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.272,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.592,percent of total billed charges,40% of total billed charges,1.28,3.4,
diazepam 5 mg Tab [FMC],2555753,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,9.288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.848,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,2.384,percent of total billed charges,40% of total billed charges,1.28,3.4,
diclofenac sodium 50 mg Oral EC Tab [FMC],2555795,CDM,250,RC,,,OUTPATIENT,1,EA,4.78,2.868,,4.06,85,,3.248,Percent of total billed charges,85% of total billed charges,2.39,50,,29.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.39,50,,7.808,percent of total billed charges,50% of total billed charges,1.53,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,1.53,31.95,,1.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.82,38,,1.456,percent of total billed charges,38% of total billed charges,1.91,40,,2.384,percent of total billed charges,40% of total billed charges,1.53,4.06,
diclofenac sodium 50 mg Oral EC Tab [FMC],2555795,CDM,250,RC,,,OUTPATIENT,1,EA,4.78,2.868,,4.06,85,,3.248,Percent of total billed charges,85% of total billed charges,2.39,50,,16.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.39,50,,9.536,percent of total billed charges,50% of total billed charges,1.53,31.95,,2.376,percent of total billed charges,31.95% of total billed charges,1.53,31.95,,2.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.82,38,,1.456,percent of total billed charges,38% of total billed charges,1.91,40,,2.976,percent of total billed charges,40% of total billed charges,1.53,4.06,
diclofenac sodium 50 mg Oral EC Tab [FMC],2555795,CDM,250,RC,,,OUTPATIENT,1,EA,3.28,1.968,,2.79,85,,2.232,Percent of total billed charges,85% of total billed charges,1.64,50,,29.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.64,50,,9.536,percent of total billed charges,50% of total billed charges,1.05,31.95,,5.328,percent of total billed charges,31.95% of total billed charges,1.05,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.25,38,,1,percent of total billed charges,38% of total billed charges,1.31,40,,4.848,percent of total billed charges,40% of total billed charges,1.05,2.79,
diclofenac sodium 75 mg Oral EC Tab [FMC],2555803,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,29.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,9.272,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.56,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.968,percent of total billed charges,40% of total billed charges,0.96,2.55,
diclofenac sodium 75 mg Oral EC Tab [FMC],2555803,CDM,250,RC,,,OUTPATIENT,1,EA,5.77,3.462,,4.9,85,,3.92,Percent of total billed charges,85% of total billed charges,2.89,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.89,50,,6.064,percent of total billed charges,50% of total billed charges,1.84,31.95,,6.176,percent of total billed charges,31.95% of total billed charges,1.84,31.95,,26.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.19,38,,1.752,percent of total billed charges,38% of total billed charges,2.31,40,,5.616,percent of total billed charges,40% of total billed charges,1.84,4.9,
diclofenac sodium 75 mg Oral EC Tab [FMC],2555803,CDM,250,RC,,,OUTPATIENT,1,EA,4.7,2.82,,4,85,,3.2,Percent of total billed charges,85% of total billed charges,2.35,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.35,50,,6.064,percent of total billed charges,50% of total billed charges,1.5,31.95,,7.104,percent of total billed charges,31.95% of total billed charges,1.5,31.95,,34.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.79,38,,1.432,percent of total billed charges,38% of total billed charges,1.88,40,,6.456,percent of total billed charges,40% of total billed charges,1.5,4,
diclofenac sodium 75 mg Oral EC Tab [FMC],2555803,CDM,250,RC,,,OUTPATIENT,1,EA,3.71,2.226,,3.15,85,,2.52,Percent of total billed charges,85% of total billed charges,1.86,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.86,50,,5.128,percent of total billed charges,50% of total billed charges,1.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.41,38,,1.128,percent of total billed charges,38% of total billed charges,1.48,40,,0.96,percent of total billed charges,40% of total billed charges,1.19,3.15,
dicyclomine 10 mg Cap [FMC],2555837,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,8.072,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
dicyclomine 10 mg Cap [FMC],2555837,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
dicyclomine 10 mg Cap [FMC],2555837,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
fluconazole 100 mg Tab [FMC],2555860,CDM,250,RC,,,OUTPATIENT,1,EA,28.61,17.166,,24.32,85,,19.456,Percent of total billed charges,85% of total billed charges,14.31,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.31,50,,1.2,percent of total billed charges,50% of total billed charges,9.14,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,9.14,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.87,38,,8.696,percent of total billed charges,38% of total billed charges,11.44,40,,0.96,percent of total billed charges,40% of total billed charges,9.14,24.32,
fluconazole 100 mg Tab [FMC],2555860,CDM,250,RC,,,OUTPATIENT,1,EA,31.55,18.93,,26.82,85,,21.456,Percent of total billed charges,85% of total billed charges,15.78,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.78,50,,2.192,percent of total billed charges,50% of total billed charges,10.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,10.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.99,38,,9.592,percent of total billed charges,38% of total billed charges,12.62,40,,0.96,percent of total billed charges,40% of total billed charges,10.08,26.82,
fluconazole 150 mg Tab [FMC],2555886,CDM,250,RC,,,OUTPATIENT,1,EA,45.28,27.168,,38.49,85,,30.792,Percent of total billed charges,85% of total billed charges,22.64,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.64,50,,1.2,percent of total billed charges,50% of total billed charges,14.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.21,38,,13.768,percent of total billed charges,38% of total billed charges,18.11,40,,0.96,percent of total billed charges,40% of total billed charges,14.47,38.49,
fluconazole 150 mg Tab [FMC],2555886,CDM,250,RC,,,OUTPATIENT,1,EA,45.53,27.318,,38.7,85,,30.96,Percent of total billed charges,85% of total billed charges,22.77,50,,51.728,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.77,50,,2.816,percent of total billed charges,50% of total billed charges,14.55,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.55,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.3,38,,13.84,percent of total billed charges,38% of total billed charges,18.21,40,,0.96,percent of total billed charges,40% of total billed charges,14.55,38.7,
fluconazole 150 mg Tab [FMC],2555886,CDM,250,RC,,,OUTPATIENT,1,EA,45.27,27.162,,38.48,85,,30.784,Percent of total billed charges,85% of total billed charges,22.64,50,,51.992,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.64,50,,2.816,percent of total billed charges,50% of total billed charges,14.46,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.46,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.2,38,,13.76,percent of total billed charges,38% of total billed charges,18.11,40,,0.96,percent of total billed charges,40% of total billed charges,14.46,38.48,
fluconazole 150 mg Tab [FMC],2555886,CDM,250,RC,,,OUTPATIENT,1,EA,45.28,27.168,,38.49,85,,30.792,Percent of total billed charges,85% of total billed charges,22.64,50,,1.288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.64,50,,2.192,percent of total billed charges,50% of total billed charges,14.47,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,14.47,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.21,38,,13.768,percent of total billed charges,38% of total billed charges,18.11,40,,1.384,percent of total billed charges,40% of total billed charges,14.47,38.49,
fluconazole 150 mg Tab [FMC],2555886,CDM,250,RC,,,OUTPATIENT,1,EA,45.54,27.324,,38.71,85,,30.968,Percent of total billed charges,85% of total billed charges,22.77,50,,1.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.77,50,,2.848,percent of total billed charges,50% of total billed charges,14.55,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.55,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.31,38,,13.848,percent of total billed charges,38% of total billed charges,18.22,40,,0.96,percent of total billed charges,40% of total billed charges,14.55,38.71,
fluconazole 150 mg Tab [FMC],2555886,CDM,250,RC,,,OUTPATIENT,1,EA,45.28,27.168,,38.49,85,,30.792,Percent of total billed charges,85% of total billed charges,22.64,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.64,50,,1.344,percent of total billed charges,50% of total billed charges,14.47,31.95,,7.84,percent of total billed charges,31.95% of total billed charges,14.47,31.95,,7.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.21,38,,13.768,percent of total billed charges,38% of total billed charges,18.11,40,,9.808,percent of total billed charges,40% of total billed charges,14.47,38.49,
fluconazole 150 mg Tab [FMC],2555886,CDM,250,RC,,,OUTPATIENT,1,EA,45.28,27.168,,38.49,85,,30.792,Percent of total billed charges,85% of total billed charges,22.64,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.64,50,,1.512,percent of total billed charges,50% of total billed charges,14.47,31.95,,8.624,percent of total billed charges,31.95% of total billed charges,14.47,31.95,,8.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.21,38,,13.768,percent of total billed charges,38% of total billed charges,18.11,40,,10.792,percent of total billed charges,40% of total billed charges,14.47,38.49,
fluconazole 200 mg/100 mL-NS IV Sol [FMC],2555894,CDM,250,RC,J1450,HCPCS,OUTPATIENT,100,ML,66.77,40.062,,56.75,85,,45.4,Percent of total billed charges,85% of total billed charges,3.47,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.47,136.6,,1.272,fee schedule,136.60% of BCBS custom fee schedule,23.47,35.15,,7.752,fee schedule,35.15% of LA custom fee schedule,21.33,31.95,,7.752,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.37,38,,20.296,percent of total billed charges,38% of total billed charges,21.33,31.95,,9.704,Fee Schedule,31.95% of LA custom fee schedule,3.47,56.75,
fluconazole 200 mg/100 mL-NS IV Sol [FMC],2555894,CDM,250,RC,J1450,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.47,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.47,136.6,,5.48,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,15.576,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,78.216,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,14.16,Fee Schedule,31.95% of LA custom fee schedule,3.47,30.6,
fluconazole 200 mg/100 mL-NS IV Sol [FMC],2555894,CDM,250,RC,J1450,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.47,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.47,136.6,,5.472,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,14.416,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,149.528,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,13.104,Fee Schedule,31.95% of LA custom fee schedule,3.47,30.6,
fluconazole 200 mg/100 mL-NS IV Sol [FMC],2555894,CDM,250,RC,J1450,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.47,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.47,136.6,,5.48,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,3.47,30.6,
digoxin immune FAB 40 mg REC [FMC],2555928,CDM,250,RC,J1162,HCPCS,OUTPATIENT,1,EA,17245.8,10347.48,,14658.93,85,,11727.144,Percent of total billed charges,85% of total billed charges,6902.3,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6902.3,136.6,,5.488,fee schedule,136.60% of BCBS custom fee schedule,6061.9,35.15,,3.32,percent of total billed charges,35.15% of total billed charges,52.72,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6553.4,38,,5242.72,percent of total billed charges,38% of total billed charges,5510.03,31.95,,4.16,percent of total billed charges,31.95% of total billed charges,52.72,14658.93,
digoxin 250 mcg/mL (0.25 mg/mL) Inj 2ml Sol [FMC],2555944,CDM,250,RC,J1160,HCPCS,OUTPATIENT,2,ML,24.29,14.574,,20.65,85,,16.52,Percent of total billed charges,85% of total billed charges,17.08,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,97.856,fee schedule,136.60% of BCBS custom fee schedule,8.54,35.15,,3.416,percent of total billed charges,35.15% of total billed charges,56.23,31.95,,3.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.23,38,,7.384,percent of total billed charges,38% of total billed charges,7.76,31.95,,4.272,percent of total billed charges,31.95% of total billed charges,7.76,56.23,
digoxin 250 mcg/mL (0.25 mg/mL) Inj 2ml Sol [FMC],2555944,CDM,250,RC,J1160,HCPCS,OUTPATIENT,2,ML,448.4,269.04,,381.14,85,,304.912,Percent of total billed charges,85% of total billed charges,17.08,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,110.84,fee schedule,136.60% of BCBS custom fee schedule,157.61,35.15,,2.04,percent of total billed charges,35.15% of total billed charges,56.23,31.95,,2.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,170.39,38,,136.312,percent of total billed charges,38% of total billed charges,143.26,31.95,,2.552,percent of total billed charges,31.95% of total billed charges,17.08,381.14,
digoxin 250 mcg/mL (0.25 mg/mL) Inj 2ml Sol [FMC],2555944,CDM,250,RC,J1160,HCPCS,OUTPATIENT,2,ML,21.45,12.87,,18.23,85,,14.584,Percent of total billed charges,85% of total billed charges,17.08,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,110.84,fee schedule,136.60% of BCBS custom fee schedule,7.54,35.15,,4.592,percent of total billed charges,35.15% of total billed charges,56.23,31.95,,4.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.15,38,,6.52,percent of total billed charges,38% of total billed charges,6.85,31.95,,5.752,percent of total billed charges,31.95% of total billed charges,6.85,56.23,
phenytoin 100 mg ERCap [FMC],2555969,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,109.616,percent of total billed charges,50% of total billed charges,0.96,31.95,,23.704,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,23.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,29.68,percent of total billed charges,40% of total billed charges,0.96,2.55,
phenytoin 100 mg ERCap [FMC],2555969,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.376,percent of total billed charges,50% of total billed charges,0.96,31.95,,51.256,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,51.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,64.176,percent of total billed charges,40% of total billed charges,0.96,2.55,
phenytoin 100 mg ERCap [FMC],2555969,CDM,250,RC,,,OUTPATIENT,1,EA,4.06,2.436,,3.45,85,,2.76,Percent of total billed charges,85% of total billed charges,2.03,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.03,50,,2.08,percent of total billed charges,50% of total billed charges,1.3,31.95,,65.384,percent of total billed charges,31.95% of total billed charges,1.3,31.95,,65.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.54,38,,1.232,percent of total billed charges,38% of total billed charges,1.62,40,,81.856,percent of total billed charges,40% of total billed charges,1.3,3.45,
phenytoin 100 mg ERCap [FMC],2555969,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,118.432,percent of total billed charges,50% of total billed charges,0.96,31.95,,65.384,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,65.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,81.856,percent of total billed charges,40% of total billed charges,0.96,2.55,
phenytoin 100 mg ERCap [FMC],2555969,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.144,percent of total billed charges,50% of total billed charges,0.96,31.95,,65.384,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,65.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,81.856,percent of total billed charges,40% of total billed charges,0.96,2.55,
HYDROmorphone 2 mg Tab [FMC],2555985,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.344,percent of total billed charges,50% of total billed charges,1.28,31.95,,17.664,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,17.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,22.112,percent of total billed charges,40% of total billed charges,1.28,3.4,
HYDROmorphone 2 mg Tab [FMC],2555985,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.376,percent of total billed charges,50% of total billed charges,1.28,31.95,,17.664,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,17.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,22.112,percent of total billed charges,40% of total billed charges,1.28,3.4,
HYDROmorphone 2 mg Tab [FMC],2555985,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.4,percent of total billed charges,50% of total billed charges,1.28,31.95,,17.664,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,17.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,22.112,percent of total billed charges,40% of total billed charges,1.28,3.4,
diltiazem 30 mg Tab [FMC],2556025,CDM,250,RC,,,OUTPATIENT,1,EA,3.25,1.95,,2.76,85,,2.208,Percent of total billed charges,85% of total billed charges,1.63,50,,32.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.63,50,,2.4,percent of total billed charges,50% of total billed charges,1.04,31.95,,32.304,percent of total billed charges,31.95% of total billed charges,1.04,31.95,,32.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.24,38,,0.992,percent of total billed charges,38% of total billed charges,1.3,40,,40.44,percent of total billed charges,40% of total billed charges,1.04,2.76,
dimenhyDRINATE 50 mg Tab [FMC],2556074,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,32.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,32.304,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,32.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,40.44,percent of total billed charges,40% of total billed charges,0.96,2.55,
valsartan 80 mg Tab [FMC],2556173,CDM,250,RC,,,OUTPATIENT,1,EA,15.75,9.45,,13.39,85,,10.712,Percent of total billed charges,85% of total billed charges,7.88,50,,32.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.88,50,,1.2,percent of total billed charges,50% of total billed charges,5.03,31.95,,21.896,percent of total billed charges,31.95% of total billed charges,5.03,31.95,,21.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.99,38,,4.792,percent of total billed charges,38% of total billed charges,6.3,40,,27.416,percent of total billed charges,40% of total billed charges,5.03,13.39,
valsartan 80 mg Tab [FMC],2556173,CDM,250,RC,,,OUTPATIENT,1,EA,15.11,9.066,,12.84,85,,10.272,Percent of total billed charges,85% of total billed charges,7.56,50,,32.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.56,50,,1.2,percent of total billed charges,50% of total billed charges,4.83,31.95,,49.264,percent of total billed charges,31.95% of total billed charges,4.83,31.95,,49.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.74,38,,4.592,percent of total billed charges,38% of total billed charges,6.04,40,,61.68,percent of total billed charges,40% of total billed charges,4.83,12.84,
valsartan 80 mg Tab [FMC],2556173,CDM,250,RC,,,OUTPATIENT,1,EA,15.22,9.132,,12.94,85,,10.352,Percent of total billed charges,85% of total billed charges,7.61,50,,32.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.61,50,,1.2,percent of total billed charges,50% of total billed charges,4.86,31.95,,49.272,percent of total billed charges,31.95% of total billed charges,4.86,31.95,,49.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.78,38,,4.624,percent of total billed charges,38% of total billed charges,6.09,40,,61.68,percent of total billed charges,40% of total billed charges,4.86,12.94,
valsartan 80 mg Tab [FMC],2556173,CDM,250,RC,,,OUTPATIENT,1,EA,15.11,9.066,,12.84,85,,10.272,Percent of total billed charges,85% of total billed charges,7.56,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.56,50,,1.2,percent of total billed charges,50% of total billed charges,4.83,31.95,,38.624,percent of total billed charges,31.95% of total billed charges,4.83,31.95,,38.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.74,38,,4.592,percent of total billed charges,38% of total billed charges,6.04,40,,48.352,percent of total billed charges,40% of total billed charges,4.83,12.84,
valsartan 80 mg Tab [FMC],2556173,CDM,250,RC,,,OUTPATIENT,1,EA,15.75,9.45,,13.39,85,,10.712,Percent of total billed charges,85% of total billed charges,7.88,50,,3.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.88,50,,1.2,percent of total billed charges,50% of total billed charges,5.03,31.95,,49.264,percent of total billed charges,31.95% of total billed charges,5.03,31.95,,49.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.99,38,,4.792,percent of total billed charges,38% of total billed charges,6.3,40,,61.68,percent of total billed charges,40% of total billed charges,5.03,13.39,
valsartan 80 mg Tab,2556173,CDM,250,RC,,,OUTPATIENT,1,EA,4.19,2.514,,3.56,85,,2.848,Percent of total billed charges,85% of total billed charges,2.1,50,,2.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.1,50,,41.656,percent of total billed charges,50% of total billed charges,1.34,31.95,,33.4,percent of total billed charges,31.95% of total billed charges,1.34,31.95,,33.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.59,38,,1.272,percent of total billed charges,38% of total billed charges,1.68,40,,41.816,percent of total billed charges,40% of total billed charges,1.34,3.56,
valsartan 80 mg Tab [FMC],2556173,CDM,250,RC,,,OUTPATIENT,1,EA,15.17,9.102,,12.89,85,,10.312,Percent of total billed charges,85% of total billed charges,7.59,50,,3.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.59,50,,76.728,percent of total billed charges,50% of total billed charges,4.85,31.95,,3.456,percent of total billed charges,31.95% of total billed charges,4.85,31.95,,3.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.76,38,,4.608,percent of total billed charges,38% of total billed charges,6.07,40,,4.328,percent of total billed charges,40% of total billed charges,4.85,12.89,
diphenhydrAMINE 50 mg/mL Inj Sol [FMC],2556207,CDM,250,RC,J1200,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.28,136.6,,2.992,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,56.88,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.112,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,3.112,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.888,Fee Schedule,31.95% of LA custom fee schedule,1.28,10.2,
diphenhydrAMINE 50 mg/mL Inj Sol [FMC],2556207,CDM,250,RC,J1200,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1.28,10.2,
diphenhydrAMINE 50 mg/mL Inj Sol [FMC],2556207,CDM,250,RC,J1200,HCPCS,OUTPATIENT,1,ML,19.5,11.7,,16.58,85,,13.264,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,1.752,fee schedule,136.60% of BCBS custom fee schedule,6.85,35.15,,3.456,fee schedule,35.15% of LA custom fee schedule,6.23,31.95,,3.456,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.41,38,,5.928,percent of total billed charges,38% of total billed charges,6.23,31.95,,4.328,Fee Schedule,31.95% of LA custom fee schedule,1.28,16.58,
diphenhydrAMINE 50 mg/mL Sol,2556207,CDM,250,RC,J1200,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.76,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1.28,10.2,
diphenhydrAMINE-zinc acetate Top 2%-0.1% Crm [FMC],2556215,CDM,250,RC,,,OUTPATIENT,30,EA,13.89,8.334,,11.81,85,,9.448,Percent of total billed charges,85% of total billed charges,6.95,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.95,50,,26.64,percent of total billed charges,50% of total billed charges,4.44,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,4.44,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.28,38,,4.224,percent of total billed charges,38% of total billed charges,5.56,40,,2.08,percent of total billed charges,40% of total billed charges,4.44,11.81,
diphenhydrAMINE-zinc acetate Top 2%-0.1% Crm [FMC],2556215,CDM,250,RC,,,OUTPATIENT,30,EA,15.15,9.09,,12.88,85,,10.304,Percent of total billed charges,85% of total billed charges,7.58,50,,3.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.58,50,,47.064,percent of total billed charges,50% of total billed charges,4.84,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,4.84,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.76,38,,4.608,percent of total billed charges,38% of total billed charges,6.06,40,,2.08,percent of total billed charges,40% of total billed charges,4.84,12.88,
propofol 10 mg/mL 100ml Emu [FMC],2556256,CDM,250,RC,J2704,HCPCS,OUTPATIENT,100,ML,109.2,65.52,,92.82,85,,74.256,Percent of total billed charges,85% of total billed charges,0.15,136.6,,4.568,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,38.38,35.15,,1.664,percent of total billed charges,35.15% of total billed charges,9.59,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.5,38,,33.2,percent of total billed charges,38% of total billed charges,34.89,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,0.15,92.82,
propofol 10 mg/mL 100ml Emu [FMC],2556256,CDM,250,RC,J2704,HCPCS,OUTPATIENT,100,ML,121.88,73.128,,103.6,85,,82.88,Percent of total billed charges,85% of total billed charges,0.15,136.6,,4.344,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,42.84,35.15,,1.664,percent of total billed charges,35.15% of total billed charges,135.47,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.31,38,,37.048,percent of total billed charges,38% of total billed charges,38.94,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,0.15,135.47,
propofol 10 mg/mL 100ml Emu [FMC],2556256,CDM,250,RC,J2704,HCPCS,OUTPATIENT,100,ML,121.88,73.128,,103.6,85,,82.88,Percent of total billed charges,85% of total billed charges,0.15,136.6,,4.568,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,42.84,35.15,,1.344,percent of total billed charges,35.15% of total billed charges,135.47,31.95,,1.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.31,38,,37.048,percent of total billed charges,38% of total billed charges,38.94,31.95,,1.688,percent of total billed charges,31.95% of total billed charges,0.15,135.47,
propofol 10 mg/mL 100ml Emu [FMC],2556256,CDM,250,RC,J2704,HCPCS,OUTPATIENT,100,ML,83.38,50.028,,70.87,85,,56.696,Percent of total billed charges,85% of total billed charges,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,29.31,35.15,,1.616,percent of total billed charges,35.15% of total billed charges,135.47,31.95,,1.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.68,38,,25.344,percent of total billed charges,38% of total billed charges,26.64,31.95,,2.024,percent of total billed charges,31.95% of total billed charges,0.15,135.47,
propofol 10 mg/mL 100ml Emu [FMC],2556256,CDM,250,RC,J2704,HCPCS,OUTPATIENT,100,ML,108.81,65.286,,92.49,85,,73.992,Percent of total billed charges,85% of total billed charges,0.15,136.6,,12.968,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,38.25,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,135.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.35,38,,33.08,percent of total billed charges,38% of total billed charges,34.76,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.15,135.47,
propofol 10 mg/mL 100ml Emu [FMC],2556256,CDM,250,RC,J2704,HCPCS,OUTPATIENT,100,ML,84.22,50.532,,71.59,85,,57.272,Percent of total billed charges,85% of total billed charges,0.15,136.6,,170.624,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,29.6,35.15,,5.296,percent of total billed charges,35.15% of total billed charges,135.47,31.95,,5.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32,38,,25.6,percent of total billed charges,38% of total billed charges,26.91,31.95,,6.624,percent of total billed charges,31.95% of total billed charges,0.15,135.47,
propofol 10 mg/mL IV 20ml Emul [FMC],2556264,CDM,250,RC,J2704,HCPCS,OUTPATIENT,20,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.15,136.6,,40.176,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.728,percent of total billed charges,35.15% of total billed charges,135.47,31.95,,4.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,5.92,percent of total billed charges,31.95% of total billed charges,0.15,135.47,
propofol 10 mg/mL IV 20ml Emul [FMC],2556264,CDM,250,RC,J2704,HCPCS,OUTPATIENT,20,ML,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,0.15,136.6,,170.728,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,5.296,percent of total billed charges,35.15% of total billed charges,56.23,31.95,,5.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,6.624,percent of total billed charges,31.95% of total billed charges,0.15,56.23,
propofol 10 mg/mL IV 20ml Emul [FMC],2556264,CDM,250,RC,J2704,HCPCS,OUTPATIENT,20,ML,21.65,12.99,,18.4,85,,14.72,Percent of total billed charges,85% of total billed charges,0.15,136.6,,5.616,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,7.61,35.15,,63.976,percent of total billed charges,35.15% of total billed charges,56.23,31.95,,63.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.23,38,,6.584,percent of total billed charges,38% of total billed charges,6.92,31.95,,80.096,percent of total billed charges,31.95% of total billed charges,0.15,56.23,
propofol 10 mg/mL IV 20ml Emul [FMC],2556264,CDM,250,RC,J2704,HCPCS,OUTPATIENT,20,ML,16.86,10.116,,14.33,85,,11.464,Percent of total billed charges,85% of total billed charges,0.15,136.6,,11.376,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,5.93,35.15,,47.144,percent of total billed charges,35.15% of total billed charges,56.23,31.95,,47.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.41,38,,5.128,percent of total billed charges,38% of total billed charges,5.39,31.95,,59.016,percent of total billed charges,31.95% of total billed charges,0.15,56.23,
propofol 10 mg/mL IV 20ml Emul [FMC],2556264,CDM,250,RC,J2704,HCPCS,OUTPATIENT,20,ML,22.67,13.602,,19.27,85,,15.416,Percent of total billed charges,85% of total billed charges,0.15,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.15,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,7.97,35.15,,24.928,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,24.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.61,38,,6.888,percent of total billed charges,38% of total billed charges,7.24,31.95,,31.216,percent of total billed charges,31.95% of total billed charges,0.15,19.27,
dipyridamole 50 mg Tab [FMC],2556322,CDM,250,RC,,,OUTPATIENT,1,EA,4.97,2.982,,4.22,85,,3.376,Percent of total billed charges,85% of total billed charges,2.49,50,,17.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.49,50,,1.2,percent of total billed charges,50% of total billed charges,1.59,31.95,,15.784,percent of total billed charges,31.95% of total billed charges,1.59,31.95,,15.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.89,38,,1.512,percent of total billed charges,38% of total billed charges,1.99,40,,19.76,percent of total billed charges,40% of total billed charges,1.59,4.22,
dipyridamole 50 mg Tab [FMC],2556322,CDM,250,RC,,,OUTPATIENT,1,EA,7.44,4.464,,6.32,85,,5.056,Percent of total billed charges,85% of total billed charges,3.72,50,,12.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.72,50,,1.2,percent of total billed charges,50% of total billed charges,2.38,31.95,,14.92,percent of total billed charges,31.95% of total billed charges,2.38,31.95,,14.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.83,38,,2.264,percent of total billed charges,38% of total billed charges,2.98,40,,18.68,percent of total billed charges,40% of total billed charges,2.38,6.32,
dipyridamole 50 mg Tab [FMC],2556322,CDM,250,RC,,,OUTPATIENT,1,EA,7.44,4.464,,6.32,85,,5.056,Percent of total billed charges,85% of total billed charges,3.72,50,,40.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.72,50,,3.008,percent of total billed charges,50% of total billed charges,2.38,31.95,,30.128,percent of total billed charges,31.95% of total billed charges,2.38,31.95,,30.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.83,38,,2.264,percent of total billed charges,38% of total billed charges,2.98,40,,37.72,percent of total billed charges,40% of total billed charges,2.38,6.32,
oxybutynin 5 mg ER Tab [FMC],2556355,CDM,250,RC,J3489,HCPCS,OUTPATIENT,1,EA,10.67,6.402,,9.07,85,,7.256,Percent of total billed charges,85% of total billed charges,10.41,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.41,136.6,,1.512,fee schedule,136.60% of BCBS custom fee schedule,3.75,35.15,,15.488,fee schedule,35.15% of LA custom fee schedule,3.41,31.95,,15.488,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.05,38,,3.24,percent of total billed charges,38% of total billed charges,3.41,31.95,,19.392,Fee Schedule,31.95% of LA custom fee schedule,3.41,10.41,
oxybutynin 5 mg ER Tab [FMC],2556355,CDM,250,RC,,,OUTPATIENT,1,EA,9.3,5.58,,7.91,85,,6.328,Percent of total billed charges,85% of total billed charges,4.65,50,,2.968,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.65,50,,7.728,percent of total billed charges,50% of total billed charges,2.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.53,38,,2.824,percent of total billed charges,38% of total billed charges,3.72,40,,0.96,percent of total billed charges,40% of total billed charges,2.97,7.91,
DOBUTamine 12.5 mg/mL IV Sol [FMC],2556363,CDM,250,RC,J1250,HCPCS,OUTPATIENT,20,ML,18.96,11.376,,16.12,85,,12.896,Percent of total billed charges,85% of total billed charges,14.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.75,136.6,,4.552,fee schedule,136.60% of BCBS custom fee schedule,6.66,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.2,38,,5.76,percent of total billed charges,38% of total billed charges,6.06,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,3.2,16.12,
DOBUTamine 12.5 mg/mL IV Sol [FMC],2556363,CDM,250,RC,J1250,HCPCS,OUTPATIENT,20,ML,23.34,14.004,,19.84,85,,15.872,Percent of total billed charges,85% of total billed charges,14.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.75,136.6,,9.168,fee schedule,136.60% of BCBS custom fee schedule,8.2,35.15,,2.408,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.87,38,,7.096,percent of total billed charges,38% of total billed charges,7.46,31.95,,3.016,percent of total billed charges,31.95% of total billed charges,3.2,19.84,
DOBUTamine 12.5 mg/mL IV Sol [FMC],2556363,CDM,250,RC,J1250,HCPCS,OUTPATIENT,20,ML,21.97,13.182,,18.67,85,,14.936,Percent of total billed charges,85% of total billed charges,14.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.75,136.6,,11.832,fee schedule,136.60% of BCBS custom fee schedule,7.72,35.15,,2.408,percent of total billed charges,35.15% of total billed charges,33.55,31.95,,2.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.35,38,,6.68,percent of total billed charges,38% of total billed charges,7.02,31.95,,3.016,percent of total billed charges,31.95% of total billed charges,7.02,33.55,
DOBUTamine 12.5 mg/mL IV Sol [FMC],2556363,CDM,250,RC,J1250,HCPCS,OUTPATIENT,20,ML,25.27,15.162,,21.48,85,,17.184,Percent of total billed charges,85% of total billed charges,14.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.75,136.6,,2.904,fee schedule,136.60% of BCBS custom fee schedule,8.88,35.15,,2.456,percent of total billed charges,35.15% of total billed charges,43.13,31.95,,2.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.6,38,,7.68,percent of total billed charges,38% of total billed charges,8.07,31.95,,3.08,percent of total billed charges,31.95% of total billed charges,8.07,43.13,
docusate sodium 100 mg Cap [FMC],2556371,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.576,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.992,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.248,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg Cap [FMC],2556371,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.664,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.088,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.624,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg Cap [FMC],2556371,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.728,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.088,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.624,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg Cap [FMC],2556371,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,13.376,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.92,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.416,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg Cap [FMC],2556371,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.432,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.872,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.848,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg Cap [FMC],2556371,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.008,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.872,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.848,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg Cap [FMC],2556371,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,16.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.112,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.272,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.096,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg/10 mL Oral Liq [FMC],2556405,CDM,250,RC,,,OUTPATIENT,10,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,55.704,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg/10 mL Oral Liq [FMC],2556405,CDM,250,RC,,,OUTPATIENT,10,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.896,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,78.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate sodium 100 mg/10 mL Oral Liq [FMC],2556405,CDM,250,RC,,,OUTPATIENT,10,ML,4.33,2.598,,3.68,85,,2.944,Percent of total billed charges,85% of total billed charges,2.17,50,,3.744,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.17,50,,28.216,percent of total billed charges,50% of total billed charges,1.38,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,1.38,31.95,,78.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.65,38,,1.32,percent of total billed charges,38% of total billed charges,1.73,40,,3.576,percent of total billed charges,40% of total billed charges,1.38,3.68,
docusate 10 mg/mL Liq,2556405,CDM,250,RC,,,OUTPATIENT,10,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.008,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
atropine/hyoscyamine/PB/scopolamine Tab [FMC],2556439,CDM,250,RC,,,OUTPATIENT,1,EA,30.66,18.396,,26.06,85,,20.848,Percent of total billed charges,85% of total billed charges,15.33,50,,2.992,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.33,50,,25.056,percent of total billed charges,50% of total billed charges,9.8,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,9.8,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.65,38,,9.32,percent of total billed charges,38% of total billed charges,12.26,40,,3.576,percent of total billed charges,40% of total billed charges,9.8,26.06,
atropine/hyoscyamine/PB/scopolamine Tab [FMC],2556439,CDM,250,RC,,,OUTPATIENT,1,EA,33.73,20.238,,28.67,85,,22.936,Percent of total billed charges,85% of total billed charges,16.87,50,,2.232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.87,50,,4.304,percent of total billed charges,50% of total billed charges,10.78,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,10.78,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.82,38,,10.256,percent of total billed charges,38% of total billed charges,13.49,40,,3.576,percent of total billed charges,40% of total billed charges,10.78,28.67,
atropine/hyoscyamine/PB/scopolamine Tab [FMC],2556439,CDM,250,RC,,,OUTPATIENT,1,EA,30.32,18.192,,25.77,85,,20.616,Percent of total billed charges,85% of total billed charges,15.16,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.16,50,,1.2,percent of total billed charges,50% of total billed charges,9.69,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,9.69,31.95,,83.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.52,38,,9.216,percent of total billed charges,38% of total billed charges,12.13,40,,3.576,percent of total billed charges,40% of total billed charges,9.69,25.77,
DOPamine 1.6 mg/mL-D5W intravenous solution [FMC],2556447,CDM,250,RC,J1265,HCPCS,OUTPATIENT,250,ML,55.4,33.24,,47.09,85,,37.672,Percent of total billed charges,85% of total billed charges,0.94,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.94,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,19.47,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,97.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.05,38,,16.84,percent of total billed charges,38% of total billed charges,17.7,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.94,97.77,
DOPamine 1.6 mg/mL-D5W intravenous solution [FMC],2556447,CDM,250,RC,J1265,HCPCS,OUTPATIENT,250,ML,51.27,30.762,,43.58,85,,34.864,Percent of total billed charges,85% of total billed charges,0.94,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.94,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,18.02,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.48,38,,15.584,percent of total billed charges,38% of total billed charges,16.38,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.94,186.91,
doxepin 25 mg Cap [FMC],2556504,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
doxycycline hyclate 100 mg Cap [FMC],2556512,CDM,250,RC,,,OUTPATIENT,1,EA,12.99,7.794,,11.04,85,,8.832,Percent of total billed charges,85% of total billed charges,6.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,1.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,3.952,percent of total billed charges,38% of total billed charges,5.2,40,,0.96,percent of total billed charges,40% of total billed charges,4.15,11.04,
doxycycline hyclate 100 mg Cap [FMC],2556512,CDM,250,RC,,,OUTPATIENT,1,EA,13.35,8.01,,11.35,85,,9.08,Percent of total billed charges,85% of total billed charges,6.68,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.68,50,,1.2,percent of total billed charges,50% of total billed charges,4.27,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,4.27,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.07,38,,4.056,percent of total billed charges,38% of total billed charges,5.34,40,,1.752,percent of total billed charges,40% of total billed charges,4.27,11.35,
doxycycline hyclate 100 mg Cap [FMC],2556512,CDM,250,RC,,,OUTPATIENT,1,EA,7.97,4.782,,6.77,85,,5.416,Percent of total billed charges,85% of total billed charges,3.99,50,,1.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.99,50,,1.2,percent of total billed charges,50% of total billed charges,2.55,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.55,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.03,38,,2.424,percent of total billed charges,38% of total billed charges,3.19,40,,0.96,percent of total billed charges,40% of total billed charges,2.55,6.77,
doxycycline hyclate 100 mg Cap,2556512,CDM,250,RC,,,OUTPATIENT,1,EA,17.98,10.788,,15.28,85,,12.224,Percent of total billed charges,85% of total billed charges,8.99,50,,2.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.99,50,,1.2,percent of total billed charges,50% of total billed charges,5.74,31.95,,1.8,percent of total billed charges,31.95% of total billed charges,5.74,31.95,,1.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.83,38,,5.464,percent of total billed charges,38% of total billed charges,7.19,40,,2.256,percent of total billed charges,40% of total billed charges,5.74,15.28,
tetanus-diphtheria toxoids adult IM Susp 0.5 mL [FMC],2556553,CDM,250,RC,,,OUTPATIENT,0.5,ML,92.74,55.644,,78.83,85,,63.064,Percent of total billed charges,85% of total billed charges,46.37,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,46.37,50,,1.2,percent of total billed charges,50% of total billed charges,29.63,31.95,,1.8,percent of total billed charges,31.95% of total billed charges,29.63,31.95,,1.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.24,38,,28.192,percent of total billed charges,38% of total billed charges,37.1,40,,2.256,percent of total billed charges,40% of total billed charges,29.63,78.83,
fentaNYL 100 mcg/hr Transderm ER Film [FMC],2556603,CDM,250,RC,,,OUTPATIENT,1,EA,200.54,120.324,,170.46,85,,136.368,Percent of total billed charges,85% of total billed charges,100.27,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100.27,50,,1.744,percent of total billed charges,50% of total billed charges,64.07,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,64.07,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76.21,38,,60.968,percent of total billed charges,38% of total billed charges,80.22,40,,1.752,percent of total billed charges,40% of total billed charges,64.07,170.46,
fentaNYL 100 mcg/hr Transderm ER Film [FMC],2556603,CDM,250,RC,,,OUTPATIENT,1,EA,255.81,153.486,,217.44,85,,173.952,Percent of total billed charges,85% of total billed charges,127.91,50,,12.984,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,127.91,50,,1.2,percent of total billed charges,50% of total billed charges,81.73,31.95,,1.816,percent of total billed charges,31.95% of total billed charges,81.73,31.95,,1.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,97.21,38,,77.768,percent of total billed charges,38% of total billed charges,102.32,40,,2.28,percent of total billed charges,40% of total billed charges,81.73,217.44,
fentaNYL 100 mcg/hr Transderm ER Film [FMC],2556603,CDM,250,RC,,,OUTPATIENT,1,EA,255.81,153.486,,217.44,85,,173.952,Percent of total billed charges,85% of total billed charges,127.91,50,,22.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,127.91,50,,1.56,percent of total billed charges,50% of total billed charges,81.73,31.95,,0.856,percent of total billed charges,31.95% of total billed charges,81.73,31.95,,0.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,97.21,38,,77.768,percent of total billed charges,38% of total billed charges,102.32,40,,1.072,percent of total billed charges,40% of total billed charges,81.73,217.44,
fentaNYL 100 mcg/hr Transderm ER Film [FMC],2556603,CDM,250,RC,,,OUTPATIENT,1,EA,255.81,153.486,,217.44,85,,173.952,Percent of total billed charges,85% of total billed charges,127.91,50,,13.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,127.91,50,,1.2,percent of total billed charges,50% of total billed charges,81.73,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,81.73,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,97.21,38,,77.768,percent of total billed charges,38% of total billed charges,102.32,40,,1.208,percent of total billed charges,40% of total billed charges,81.73,217.44,
fentaNYL 25 mcg/hr Transderm ER Film [FMC],2556611,CDM,250,RC,,,OUTPATIENT,1,EA,69.11,41.466,,58.74,85,,46.992,Percent of total billed charges,85% of total billed charges,34.56,50,,7.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34.56,50,,5.824,percent of total billed charges,50% of total billed charges,22.08,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,22.08,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.26,38,,21.008,percent of total billed charges,38% of total billed charges,27.64,40,,1.016,percent of total billed charges,40% of total billed charges,22.08,58.74,
fentaNYL 25 mcg/hr Transderm ER Film [FMC],2556611,CDM,250,RC,,,OUTPATIENT,1,EA,69.11,41.466,,58.74,85,,46.992,Percent of total billed charges,85% of total billed charges,34.56,50,,27.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34.56,50,,1.2,percent of total billed charges,50% of total billed charges,22.08,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,22.08,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.26,38,,21.008,percent of total billed charges,38% of total billed charges,27.64,40,,4.384,percent of total billed charges,40% of total billed charges,22.08,58.74,
fentaNYL 25 mcg/hr Transderm ER Film [FMC],2556611,CDM,250,RC,,,OUTPATIENT,1,EA,69.11,41.466,,58.74,85,,46.992,Percent of total billed charges,85% of total billed charges,34.56,50,,5.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34.56,50,,1.2,percent of total billed charges,50% of total billed charges,22.08,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,22.08,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.26,38,,21.008,percent of total billed charges,38% of total billed charges,27.64,40,,4.376,percent of total billed charges,40% of total billed charges,22.08,58.74,
fentaNYL 50 mcg/hr Transderm ER Film [FMC],2556629,CDM,250,RC,,,OUTPATIENT,1,EA,126.37,75.822,,107.41,85,,85.928,Percent of total billed charges,85% of total billed charges,63.19,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,63.19,50,,1.2,percent of total billed charges,50% of total billed charges,40.38,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,40.38,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.02,38,,38.416,percent of total billed charges,38% of total billed charges,50.55,40,,4.384,percent of total billed charges,40% of total billed charges,40.38,107.41,
fentaNYL 50 mcg/hr Transderm ER Film [FMC],2556629,CDM,250,RC,,,OUTPATIENT,1,EA,126.37,75.822,,107.41,85,,85.928,Percent of total billed charges,85% of total billed charges,63.19,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,63.19,50,,1.2,percent of total billed charges,50% of total billed charges,40.38,31.95,,3.504,percent of total billed charges,31.95% of total billed charges,40.38,31.95,,3.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.02,38,,38.416,percent of total billed charges,38% of total billed charges,50.55,40,,4.384,percent of total billed charges,40% of total billed charges,40.38,107.41,
fentaNYL 50 mcg/hr Transderm ER Film [FMC],2556629,CDM,250,RC,,,OUTPATIENT,1,EA,85.67,51.402,,72.82,85,,58.256,Percent of total billed charges,85% of total billed charges,42.84,50,,21.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.84,50,,1.2,percent of total billed charges,50% of total billed charges,27.37,31.95,,62.528,percent of total billed charges,31.95% of total billed charges,27.37,31.95,,62.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.55,38,,26.04,percent of total billed charges,38% of total billed charges,34.27,40,,78.28,percent of total billed charges,40% of total billed charges,27.37,72.82,
fentaNYL 75 mcg/hr Transderm ER Film [FMC],2556645,CDM,250,RC,,,OUTPATIENT,1,EA,192.74,115.644,,163.83,85,,131.064,Percent of total billed charges,85% of total billed charges,96.37,50,,7.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.37,50,,2.4,percent of total billed charges,50% of total billed charges,61.58,31.95,,70.824,percent of total billed charges,31.95% of total billed charges,61.58,31.95,,70.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.24,38,,58.592,percent of total billed charges,38% of total billed charges,77.1,40,,88.672,percent of total billed charges,40% of total billed charges,61.58,163.83,
fentaNYL 75 mcg/hr Transderm ER Film [FMC],2556645,CDM,250,RC,,,OUTPATIENT,1,EA,192.76,115.656,,163.85,85,,131.08,Percent of total billed charges,85% of total billed charges,96.38,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.38,50,,2.4,percent of total billed charges,50% of total billed charges,61.59,31.95,,70.824,percent of total billed charges,31.95% of total billed charges,61.59,31.95,,70.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.25,38,,58.6,percent of total billed charges,38% of total billed charges,77.1,40,,88.672,percent of total billed charges,40% of total billed charges,61.59,163.85,
fentaNYL 75 mcg/hr Transderm ER Film [FMC],2556645,CDM,250,RC,,,OUTPATIENT,1,EA,151.1,90.66,,128.44,85,,102.752,Percent of total billed charges,85% of total billed charges,75.55,50,,10.536,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75.55,50,,1.2,percent of total billed charges,50% of total billed charges,48.28,31.95,,70.048,percent of total billed charges,31.95% of total billed charges,48.28,31.95,,70.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57.42,38,,45.936,percent of total billed charges,38% of total billed charges,60.44,40,,87.696,percent of total billed charges,40% of total billed charges,48.28,128.44,
fentaNYL 75 mcg/hr Transderm ER Film [FMC],2556645,CDM,250,RC,,,OUTPATIENT,1,EA,192.74,115.644,,163.83,85,,131.064,Percent of total billed charges,85% of total billed charges,96.37,50,,6.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.37,50,,1.2,percent of total billed charges,50% of total billed charges,61.58,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,61.58,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.24,38,,58.592,percent of total billed charges,38% of total billed charges,77.1,40,,1.096,percent of total billed charges,40% of total billed charges,61.58,163.83,
fentaNYL 75 mcg/hr Transderm ER Film [FMC],2556645,CDM,250,RC,,,OUTPATIENT,1,EA,130.68,78.408,,111.08,85,,88.864,Percent of total billed charges,85% of total billed charges,65.34,50,,6.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,65.34,50,,1.2,percent of total billed charges,50% of total billed charges,41.75,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,41.75,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.66,38,,39.728,percent of total billed charges,38% of total billed charges,52.27,40,,1.664,percent of total billed charges,40% of total billed charges,41.75,111.08,
venlafaxine 37.5 mg ERCap [FMC],2556785,CDM,250,RC,,,OUTPATIENT,1,EA,13.53,8.118,,11.5,85,,9.2,Percent of total billed charges,85% of total billed charges,6.77,50,,13.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.77,50,,1.2,percent of total billed charges,50% of total billed charges,4.32,31.95,,75.68,percent of total billed charges,31.95% of total billed charges,4.32,31.95,,75.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.14,38,,4.112,percent of total billed charges,38% of total billed charges,5.41,40,,94.744,percent of total billed charges,40% of total billed charges,4.32,11.5,
venlafaxine 37.5 mg ERCap [FMC],2556785,CDM,250,RC,,,OUTPATIENT,1,EA,12.16,7.296,,10.34,85,,8.272,Percent of total billed charges,85% of total billed charges,6.08,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.08,50,,1.2,percent of total billed charges,50% of total billed charges,3.89,31.95,,2.008,percent of total billed charges,31.95% of total billed charges,3.89,31.95,,2.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.62,38,,3.696,percent of total billed charges,38% of total billed charges,4.86,40,,2.512,percent of total billed charges,40% of total billed charges,3.89,10.34,
venlafaxine 37.5 mg ERCap [FMC],2556785,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.136,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.672,percent of total billed charges,40% of total billed charges,0.96,2.55,
venlafaxine 37.5 mg ERCap [FMC],2556785,CDM,250,RC,,,OUTPATIENT,1,EA,13.53,8.118,,11.5,85,,9.2,Percent of total billed charges,85% of total billed charges,6.77,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.77,50,,2.304,percent of total billed charges,50% of total billed charges,4.32,31.95,,2.16,percent of total billed charges,31.95% of total billed charges,4.32,31.95,,2.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.14,38,,4.112,percent of total billed charges,38% of total billed charges,5.41,40,,2.704,percent of total billed charges,40% of total billed charges,4.32,11.5,
venlafaxine 37.5 mg ERCap [FMC],2556785,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.272,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
venlafaxine 37.5 mg Tab [FMC],2556793,CDM,250,RC,,,OUTPATIENT,1,EA,6.5,3.9,,5.53,85,,4.424,Percent of total billed charges,85% of total billed charges,3.25,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,1.424,percent of total billed charges,50% of total billed charges,2.08,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,2.08,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,1.92,percent of total billed charges,40% of total billed charges,2.08,5.53,
venlafaxine 37.5 mg Tab [FMC],2556793,CDM,250,RC,,,OUTPATIENT,1,EA,6.5,3.9,,5.53,85,,4.424,Percent of total billed charges,85% of total billed charges,3.25,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,1.2,percent of total billed charges,50% of total billed charges,2.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,0.96,percent of total billed charges,40% of total billed charges,2.08,5.53,
venlafaxine 37.5 mg Tab [FMC],2556793,CDM,250,RC,,,OUTPATIENT,1,EA,6.5,3.9,,5.53,85,,4.424,Percent of total billed charges,85% of total billed charges,3.25,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,1.2,percent of total billed charges,50% of total billed charges,2.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,0.96,percent of total billed charges,40% of total billed charges,2.08,5.53,
venlafaxine 37.5 mg Tab [FMC],2556793,CDM,250,RC,,,OUTPATIENT,1,EA,6.5,3.9,,5.53,85,,4.424,Percent of total billed charges,85% of total billed charges,3.25,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,1.2,percent of total billed charges,50% of total billed charges,2.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,0.96,percent of total billed charges,40% of total billed charges,2.08,5.53,
enalapril 10 mg Tab [FMC],2556900,CDM,250,RC,,,OUTPATIENT,1,EA,5.27,3.162,,4.48,85,,3.584,Percent of total billed charges,85% of total billed charges,2.64,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.64,50,,1.2,percent of total billed charges,50% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2,38,,1.6,percent of total billed charges,38% of total billed charges,2.11,40,,0.96,percent of total billed charges,40% of total billed charges,1.68,4.48,
enalapril 10 mg Tab [FMC],2556900,CDM,250,RC,,,OUTPATIENT,1,EA,6.32,3.792,,5.37,85,,4.296,Percent of total billed charges,85% of total billed charges,3.16,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.16,50,,1.2,percent of total billed charges,50% of total billed charges,2.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.4,38,,1.92,percent of total billed charges,38% of total billed charges,2.53,40,,0.96,percent of total billed charges,40% of total billed charges,2.02,5.37,
enalapril 10 mg Tab [FMC],2556900,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
enalapril 1.25 mg/mL IV Sol [FMC],2556934,CDM,250,RC,,,OUTPATIENT,1,ML,20.71,12.426,,17.6,85,,14.08,Percent of total billed charges,85% of total billed charges,10.36,50,,280.832,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.36,50,,4.8,percent of total billed charges,50% of total billed charges,6.62,31.95,,26.616,percent of total billed charges,31.95% of total billed charges,6.62,31.95,,26.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.87,38,,6.296,percent of total billed charges,38% of total billed charges,8.28,40,,33.32,percent of total billed charges,40% of total billed charges,6.62,17.6,
enalapril 1.25 mg/mL IV Sol [FMC],2556934,CDM,250,RC,,,OUTPATIENT,1,ML,18.49,11.094,,15.72,85,,12.576,Percent of total billed charges,85% of total billed charges,9.25,50,,3.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.25,50,,4.8,percent of total billed charges,50% of total billed charges,5.91,31.95,,49.032,percent of total billed charges,31.95% of total billed charges,5.91,31.95,,49.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.03,38,,5.624,percent of total billed charges,38% of total billed charges,7.4,40,,61.384,percent of total billed charges,40% of total billed charges,5.91,15.72,
enalapril 1.25 mg/mL IV Sol [FMC],2556934,CDM,250,RC,,,OUTPATIENT,1,ML,20.71,12.426,,17.6,85,,14.08,Percent of total billed charges,85% of total billed charges,10.36,50,,1.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.36,50,,43.984,percent of total billed charges,50% of total billed charges,6.62,31.95,,36.344,percent of total billed charges,31.95% of total billed charges,6.62,31.95,,36.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.87,38,,6.296,percent of total billed charges,38% of total billed charges,8.28,40,,45.504,percent of total billed charges,40% of total billed charges,6.62,17.6,
hepatitis B adult vaccine 20 mcg/mL Sus [FMC],2556959,CDM,250,RC,,,OUTPATIENT,1,ML,250.3,150.18,,212.76,85,,170.208,Percent of total billed charges,85% of total billed charges,125.15,50,,2.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,125.15,50,,48.976,percent of total billed charges,50% of total billed charges,79.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,79.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95.11,38,,76.088,percent of total billed charges,38% of total billed charges,100.12,40,,0.96,percent of total billed charges,40% of total billed charges,79.97,212.76,
ePHEDrine 50 mg/mL Inj Sol [FMC],2557007,CDM,250,RC,,,OUTPATIENT,1,ML,184.43,110.658,,156.77,85,,125.416,Percent of total billed charges,85% of total billed charges,92.22,50,,1.808,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,92.22,50,,51.336,percent of total billed charges,50% of total billed charges,58.93,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,58.93,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.08,38,,56.064,percent of total billed charges,38% of total billed charges,73.77,40,,1.4,percent of total billed charges,40% of total billed charges,58.93,156.77,
ePHEDrine 50 mg/mL Inj Sol [FMC],2557007,CDM,250,RC,,,OUTPATIENT,1,ML,97.54,58.524,,82.91,85,,66.328,Percent of total billed charges,85% of total billed charges,48.77,50,,3.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48.77,50,,4.4,percent of total billed charges,50% of total billed charges,31.16,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,31.16,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.07,38,,29.656,percent of total billed charges,38% of total billed charges,39.02,40,,0.96,percent of total billed charges,40% of total billed charges,31.16,82.91,
EPINEPHrine 1 mg/mL Inj Sol [FMC],2557015,CDM,250,RC,J0171,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.17,136.6,,2.696,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,3.28,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,17.024,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,17.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,21.312,Fee Schedule,31.95% of LA custom fee schedule,1.17,10.2,
EPINEPHrine 1 mg/mL Inj Sol [FMC],2557015,CDM,250,RC,J0171,HCPCS,OUTPATIENT,1,ML,58.34,35.004,,49.59,85,,39.672,Percent of total billed charges,85% of total billed charges,1.17,136.6,,4.616,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,20.51,35.15,,30.072,fee schedule,35.15% of LA custom fee schedule,18.64,31.95,,30.072,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.17,38,,17.736,percent of total billed charges,38% of total billed charges,18.64,31.95,,37.648,Fee Schedule,31.95% of LA custom fee schedule,1.17,49.59,
"epinephrine inj 1:10,000 1mg(0.1mg/mL) [FMC]",2557023,CDM,250,RC,J0171,HCPCS,OUTPATIENT,10,ML,20.81,12.486,,17.69,85,,14.152,Percent of total billed charges,85% of total billed charges,1.17,136.6,,4.616,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,7.31,35.15,,6.4,fee schedule,35.15% of LA custom fee schedule,6.65,31.95,,83.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.91,38,,6.328,percent of total billed charges,38% of total billed charges,6.65,31.95,,5.816,Fee Schedule,31.95% of LA custom fee schedule,1.17,17.69,
"epinephrine inj 1:10,000 1mg(0.1mg/mL) [FMC]",2557023,CDM,250,RC,J0171,HCPCS,OUTPATIENT,10,ML,22.75,13.65,,19.34,85,,15.472,Percent of total billed charges,85% of total billed charges,1.17,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8,35.15,,25.616,fee schedule,35.15% of LA custom fee schedule,7.27,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.65,38,,6.92,percent of total billed charges,38% of total billed charges,7.27,31.95,,23.288,Fee Schedule,31.95% of LA custom fee schedule,1.17,19.34,
"epinephrine inj 1:10,000 1mg(0.1mg/mL) [FMC]",2557023,CDM,250,RC,J0171,HCPCS,OUTPATIENT,10,ML,38.42,23.052,,32.66,85,,26.128,Percent of total billed charges,85% of total billed charges,1.17,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,13.5,35.15,,3.4,fee schedule,35.15% of LA custom fee schedule,12.28,31.95,,2.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.6,38,,11.68,percent of total billed charges,38% of total billed charges,12.28,31.95,,3.088,Fee Schedule,31.95% of LA custom fee schedule,1.17,32.66,
"epinephrine inj 1:10,000 1mg(0.1mg/mL) [FMC]",2557023,CDM,250,RC,J0171,HCPCS,OUTPATIENT,10,ML,27.19,16.314,,23.11,85,,18.488,Percent of total billed charges,85% of total billed charges,1.17,136.6,,23.792,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,5.264,fee schedule,136.60% of BCBS custom fee schedule,9.56,35.15,,4.376,fee schedule,35.15% of LA custom fee schedule,8.69,31.95,,21.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.33,38,,8.264,percent of total billed charges,38% of total billed charges,8.69,31.95,,3.976,Fee Schedule,31.95% of LA custom fee schedule,1.17,23.11,
"epinephrine inj 1:10,000 1mg(0.1mg/mL) [FMC]",2557023,CDM,250,RC,J0171,HCPCS,OUTPATIENT,10,ML,48.75,29.25,,41.44,85,,33.152,Percent of total billed charges,85% of total billed charges,1.17,136.6,,24.768,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,6.768,fee schedule,136.60% of BCBS custom fee schedule,17.14,35.15,,3.712,fee schedule,35.15% of LA custom fee schedule,15.58,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.53,38,,14.824,percent of total billed charges,38% of total billed charges,15.58,31.95,,3.376,Fee Schedule,31.95% of LA custom fee schedule,1.17,41.44,
"epoetin alfa 10,000 units/mL Inj Sol [FMC]",2557056,CDM,250,RC,J0885,HCPCS,OUTPATIENT,1,ML,1042.28,625.368,,885.94,85,,708.752,Percent of total billed charges,85% of total billed charges,10.65,136.6,,29.72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.65,136.6,,3.76,fee schedule,136.60% of BCBS custom fee schedule,366.36,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,333.01,31.95,,4.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,396.07,38,,316.856,percent of total billed charges,38% of total billed charges,333.01,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,10.65,885.94,
erythromycin lactobionate 500 mg Inj [FMC],2557163,CDM,250,RC,J1364,HCPCS,OUTPATIENT,1,EA,329.69,197.814,,280.24,85,,224.192,Percent of total billed charges,85% of total billed charges,125.67,136.6,,47.288,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,125.67,136.6,,6.768,fee schedule,136.60% of BCBS custom fee schedule,115.89,35.15,,4.864,fee schedule,35.15% of LA custom fee schedule,105.34,31.95,,7.592,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,125.28,38,,100.224,percent of total billed charges,38% of total billed charges,105.34,31.95,,4.424,Fee Schedule,31.95% of LA custom fee schedule,105.34,280.24,
erythromycin lactobionate 500 mg Inj [FMC],2557163,CDM,250,RC,J1364,HCPCS,OUTPATIENT,1,EA,322.23,193.338,,273.9,85,,219.12,Percent of total billed charges,85% of total billed charges,125.67,136.6,,43.208,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,125.67,136.6,,5.712,fee schedule,136.60% of BCBS custom fee schedule,113.26,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,102.95,31.95,,9.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,122.45,38,,97.96,percent of total billed charges,38% of total billed charges,102.95,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,102.95,273.9,
erythromycin Ophth 0.5% Oint [FMC],2557171,CDM,250,RC,,,OUTPATIENT,3.5,EA,61.75,37.05,,52.49,85,,41.992,Percent of total billed charges,85% of total billed charges,30.88,50,,43.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.88,50,,3.952,percent of total billed charges,50% of total billed charges,19.73,31.95,,6.776,percent of total billed charges,31.95% of total billed charges,19.73,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.47,38,,18.776,percent of total billed charges,38% of total billed charges,24.7,40,,6.16,percent of total billed charges,40% of total billed charges,19.73,52.49,
erythromycin Ophth 0.5% Oint [FMC],2557171,CDM,250,RC,,,OUTPATIENT,3.5,EA,58.37,35.022,,49.61,85,,39.688,Percent of total billed charges,85% of total billed charges,29.19,50,,43.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.19,50,,3.056,percent of total billed charges,50% of total billed charges,18.65,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,18.65,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.18,38,,17.744,percent of total billed charges,38% of total billed charges,23.35,40,,3.064,percent of total billed charges,40% of total billed charges,18.65,49.61,
erythromycin Ophth 0.5% Oint [FMC],2557171,CDM,250,RC,,,OUTPATIENT,3.5,EA,117.88,70.728,,100.2,85,,80.16,Percent of total billed charges,85% of total billed charges,58.94,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,58.94,50,,5.312,percent of total billed charges,50% of total billed charges,37.66,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,37.66,31.95,,7.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.79,38,,35.832,percent of total billed charges,38% of total billed charges,47.15,40,,3.064,percent of total billed charges,40% of total billed charges,37.66,100.2,
erythromycin Ophth 0.5% Oint [FMC],2557171,CDM,250,RC,,,OUTPATIENT,3.5,EA,60.61,36.366,,51.52,85,,41.216,Percent of total billed charges,85% of total billed charges,30.31,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.31,50,,2.168,percent of total billed charges,50% of total billed charges,19.36,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,19.36,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.03,38,,18.424,percent of total billed charges,38% of total billed charges,24.24,40,,0.96,percent of total billed charges,40% of total billed charges,19.36,51.52,
estradiol 1 mg Tab [FMC],2557205,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.312,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
estradiol 1 mg Tab [FMC],2557205,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
etodolac 400 mg ER Tab [FMC],2557288,CDM,250,RC,,,OUTPATIENT,1,EA,9.43,5.658,,8.02,85,,6.416,Percent of total billed charges,85% of total billed charges,4.72,50,,5.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.72,50,,1.2,percent of total billed charges,50% of total billed charges,3.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.58,38,,2.864,percent of total billed charges,38% of total billed charges,3.77,40,,0.96,percent of total billed charges,40% of total billed charges,3.01,8.02,
etodolac 400 mg ER Tab [FMC],2557288,CDM,250,RC,,,OUTPATIENT,1,EA,9.43,5.658,,8.02,85,,6.416,Percent of total billed charges,85% of total billed charges,4.72,50,,5.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.72,50,,1.2,percent of total billed charges,50% of total billed charges,3.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.58,38,,2.864,percent of total billed charges,38% of total billed charges,3.77,40,,0.96,percent of total billed charges,40% of total billed charges,3.01,8.02,
etodolac 400 mg ER Tab [FMC],2557288,CDM,250,RC,,,OUTPATIENT,1,EA,9.62,5.772,,8.18,85,,6.544,Percent of total billed charges,85% of total billed charges,4.81,50,,7.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.81,50,,9.288,percent of total billed charges,50% of total billed charges,3.07,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,3.07,31.95,,8.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.66,38,,2.928,percent of total billed charges,38% of total billed charges,3.85,40,,3.128,percent of total billed charges,40% of total billed charges,3.07,8.18,
raloxifene 60 mg Tab [FMC],2557320,CDM,250,RC,,,OUTPATIENT,1,EA,19.52,11.712,,16.59,85,,13.272,Percent of total billed charges,85% of total billed charges,9.76,50,,8.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.76,50,,29.44,percent of total billed charges,50% of total billed charges,6.24,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,6.24,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.42,38,,5.936,percent of total billed charges,38% of total billed charges,7.81,40,,3.064,percent of total billed charges,40% of total billed charges,6.24,16.59,
raloxifene 60 mg Tab [FMC],2557320,CDM,250,RC,,,OUTPATIENT,1,EA,23.83,14.298,,20.26,85,,16.208,Percent of total billed charges,85% of total billed charges,11.92,50,,6.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.92,50,,16.064,percent of total billed charges,50% of total billed charges,7.61,31.95,,3.872,percent of total billed charges,31.95% of total billed charges,7.61,31.95,,15.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.06,38,,7.248,percent of total billed charges,38% of total billed charges,9.53,40,,3.52,percent of total billed charges,40% of total billed charges,7.61,20.26,
raloxifene 60 mg Tab [FMC],2557320,CDM,250,RC,,,OUTPATIENT,1,EA,23.83,14.298,,20.26,85,,16.208,Percent of total billed charges,85% of total billed charges,11.92,50,,1.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.92,50,,29.472,percent of total billed charges,50% of total billed charges,7.61,31.95,,3.696,percent of total billed charges,31.95% of total billed charges,7.61,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.06,38,,7.248,percent of total billed charges,38% of total billed charges,9.53,40,,3.36,percent of total billed charges,40% of total billed charges,7.61,20.26,
raloxifene 60 mg Tab [FMC],2557320,CDM,250,RC,,,OUTPATIENT,1,EA,23.17,13.902,,19.69,85,,15.752,Percent of total billed charges,85% of total billed charges,11.59,50,,1.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.59,50,,29.44,percent of total billed charges,50% of total billed charges,7.4,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,7.4,31.95,,7.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.8,38,,7.04,percent of total billed charges,38% of total billed charges,9.27,40,,3.064,percent of total billed charges,40% of total billed charges,7.4,19.69,
rivastigmine 1.5 mg Cap [FMC],2557346,CDM,250,RC,,,OUTPATIENT,1,EA,15.15,9.09,,12.88,85,,10.304,Percent of total billed charges,85% of total billed charges,7.58,50,,1.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.58,50,,1.2,percent of total billed charges,50% of total billed charges,4.84,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,4.84,31.95,,7.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.76,38,,4.608,percent of total billed charges,38% of total billed charges,6.06,40,,3.488,percent of total billed charges,40% of total billed charges,4.84,12.88,
rivastigmine 1.5 mg Cap [FMC],2557346,CDM,250,RC,,,OUTPATIENT,1,EA,15.15,9.09,,12.88,85,,10.304,Percent of total billed charges,85% of total billed charges,7.58,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.58,50,,1.2,percent of total billed charges,50% of total billed charges,4.84,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,4.84,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.76,38,,4.608,percent of total billed charges,38% of total billed charges,6.06,40,,3.128,percent of total billed charges,40% of total billed charges,4.84,12.88,
rivastigmine 1.5 mg Cap [FMC],2557346,CDM,250,RC,,,OUTPATIENT,1,EA,12.81,7.686,,10.89,85,,8.712,Percent of total billed charges,85% of total billed charges,6.41,50,,2.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.41,50,,1.2,percent of total billed charges,50% of total billed charges,4.09,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.09,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.87,38,,3.896,percent of total billed charges,38% of total billed charges,5.12,40,,0.96,percent of total billed charges,40% of total billed charges,4.09,10.89,
fentaNYL 0.05 mg/mL Inj 2 mL Sol [FMC],2557429,CDM,250,RC,J3010,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,23.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,23.96,
fentaNYL 0.05 mg/mL Inj 2 mL Sol [FMC],2557429,CDM,250,RC,J3010,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,97.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,97.77,
fentaNYL 0.05 mg/mL Inj 2 mL Sol [FMC],2557429,CDM,250,RC,J3010,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,97.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,97.77,
fentaNYL 0.05 mg/mL Inj 2 mL Sol [FMC],2557429,CDM,250,RC,J3010,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,111.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,111.83,
fentaNYL 0.05 mg/mL Inj 2 mL Sol [FMC],2557429,CDM,250,RC,J3010,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,191.7,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,191.7,
fentaNYL 0.05 mg/mL Inj 2 mL Sol [FMC],2557429,CDM,250,RC,J3010,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,34.51,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,34.51,
fentaNYL 0.05 mg/mL Inj 2 mL Sol [FMC],2557429,CDM,250,RC,J3010,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,5.616,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,104.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,104.8,
ferrous sulfate 325 mg Oral EC Tab [FMC],2557478,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.072,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.408,percent of total billed charges,40% of total billed charges,0.96,2.55,
ferrous sulfate 325 mg Oral EC Tab [FMC],2557478,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.968,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.208,percent of total billed charges,40% of total billed charges,0.96,2.55,
polycarbophil 625 mg Tab [FMC],2557494,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.912,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.48,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.176,percent of total billed charges,40% of total billed charges,0.96,2.55,
polycarbophil 625 mg Tab [FMC],2557494,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.912,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.64,percent of total billed charges,40% of total billed charges,0.96,2.55,
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [FMC],2557528,CDM,250,RC,,,OUTPATIENT,1,EA,5.48,3.288,,4.66,85,,3.728,Percent of total billed charges,85% of total billed charges,2.74,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.74,50,,1.2,percent of total billed charges,50% of total billed charges,1.75,31.95,,5.856,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,5.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.08,38,,1.664,percent of total billed charges,38% of total billed charges,2.19,40,,7.328,percent of total billed charges,40% of total billed charges,1.75,4.66,
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [FMC],2557528,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.56,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.464,percent of total billed charges,40% of total billed charges,0.96,2.55,
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [FMC],2557528,CDM,250,RC,,,OUTPATIENT,1,EA,7.04,4.224,,5.98,85,,4.784,Percent of total billed charges,85% of total billed charges,3.52,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.52,50,,51.728,percent of total billed charges,50% of total billed charges,2.25,31.95,,1.856,percent of total billed charges,31.95% of total billed charges,2.25,31.95,,1.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.68,38,,2.144,percent of total billed charges,38% of total billed charges,2.82,40,,2.32,percent of total billed charges,40% of total billed charges,2.25,5.98,
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [FMC],2557528,CDM,250,RC,,,OUTPATIENT,1,EA,7.04,4.224,,5.98,85,,4.784,Percent of total billed charges,85% of total billed charges,3.52,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.52,50,,51.992,percent of total billed charges,50% of total billed charges,2.25,31.95,,7.392,percent of total billed charges,31.95% of total billed charges,2.25,31.95,,7.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.68,38,,2.144,percent of total billed charges,38% of total billed charges,2.82,40,,9.256,percent of total billed charges,40% of total billed charges,2.25,5.98,
APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [FMC],2557528,CDM,250,RC,,,OUTPATIENT,1,EA,5.48,3.288,,4.66,85,,3.728,Percent of total billed charges,85% of total billed charges,2.74,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.74,50,,1.288,percent of total billed charges,50% of total billed charges,1.75,31.95,,1.704,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,1.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.08,38,,1.664,percent of total billed charges,38% of total billed charges,2.19,40,,2.128,percent of total billed charges,40% of total billed charges,1.75,4.66,
Saline PEDIATRIC Enema 2-11yrs 66 mL [FMC],2557551,CDM,250,RC,,,OUTPATIENT,66,ML,7.12,4.272,,6.05,85,,4.84,Percent of total billed charges,85% of total billed charges,3.56,50,,1.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.56,50,,1.304,percent of total billed charges,50% of total billed charges,2.27,31.95,,4.936,percent of total billed charges,31.95% of total billed charges,2.27,31.95,,4.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.71,38,,2.168,percent of total billed charges,38% of total billed charges,2.85,40,,6.184,percent of total billed charges,40% of total billed charges,2.27,6.05,
Saline ADULT Enema 133 mL [FMC],2557569,CDM,250,RC,,,OUTPATIENT,133,ML,3.35,2.01,,2.85,85,,2.28,Percent of total billed charges,85% of total billed charges,1.68,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.68,50,,1.2,percent of total billed charges,50% of total billed charges,1.07,31.95,,8.544,percent of total billed charges,31.95% of total billed charges,1.07,31.95,,8.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.27,38,,1.016,percent of total billed charges,38% of total billed charges,1.34,40,,10.704,percent of total billed charges,40% of total billed charges,1.07,2.85,
Saline ADULT Enema 133 mL [FMC],2557569,CDM,250,RC,,,OUTPATIENT,133,ML,3.77,2.262,,3.2,85,,2.56,Percent of total billed charges,85% of total billed charges,1.89,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.89,50,,1.2,percent of total billed charges,50% of total billed charges,1.2,31.95,,1.552,percent of total billed charges,31.95% of total billed charges,1.2,31.95,,1.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.43,38,,1.144,percent of total billed charges,38% of total billed charges,1.51,40,,1.944,percent of total billed charges,40% of total billed charges,1.2,3.2,
mineral oil lubricant laxative 30 mL UD [FMC],2557577,CDM,250,RC,,,OUTPATIENT,30,ML,3.17,1.902,,2.69,85,,2.152,Percent of total billed charges,85% of total billed charges,1.59,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.59,50,,1.2,percent of total billed charges,50% of total billed charges,1.01,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,1.01,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.2,38,,0.96,percent of total billed charges,38% of total billed charges,1.27,40,,4.808,percent of total billed charges,40% of total billed charges,1.01,2.69,
tamsulosin 0.4 mg Oral Cap [FMC],2557585,CDM,250,RC,,,OUTPATIENT,1,EA,13.69,8.214,,11.64,85,,9.312,Percent of total billed charges,85% of total billed charges,6.85,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.85,50,,1.2,percent of total billed charges,50% of total billed charges,4.37,31.95,,1.984,percent of total billed charges,31.95% of total billed charges,4.37,31.95,,1.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.2,38,,4.16,percent of total billed charges,38% of total billed charges,5.48,40,,2.488,percent of total billed charges,40% of total billed charges,4.37,11.64,
tamsulosin 0.4 mg Oral Cap [FMC],2557585,CDM,250,RC,,,OUTPATIENT,1,EA,13.68,8.208,,11.63,85,,9.304,Percent of total billed charges,85% of total billed charges,6.84,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.84,50,,1.2,percent of total billed charges,50% of total billed charges,4.37,31.95,,35.592,percent of total billed charges,31.95% of total billed charges,4.37,31.95,,35.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.2,38,,4.16,percent of total billed charges,38% of total billed charges,5.47,40,,44.56,percent of total billed charges,40% of total billed charges,4.37,11.63,
tamsulosin 0.4 mg Cap [FMC],2557585,CDM,250,RC,,,OUTPATIENT,1,EA,13.69,8.214,,11.64,85,,9.312,Percent of total billed charges,85% of total billed charges,6.85,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.85,50,,1.2,percent of total billed charges,50% of total billed charges,4.37,31.95,,4.4,percent of total billed charges,31.95% of total billed charges,4.37,31.95,,4.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.2,38,,4.16,percent of total billed charges,38% of total billed charges,5.48,40,,5.512,percent of total billed charges,40% of total billed charges,4.37,11.64,
tamsulosin 0.4 mg Oral Cap [FMC],2557585,CDM,250,RC,,,OUTPATIENT,1,EA,13.71,8.226,,11.65,85,,9.32,Percent of total billed charges,85% of total billed charges,6.86,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.86,50,,1.2,percent of total billed charges,50% of total billed charges,4.38,31.95,,18.024,percent of total billed charges,31.95% of total billed charges,4.38,31.95,,18.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.21,38,,4.168,percent of total billed charges,38% of total billed charges,5.48,40,,22.568,percent of total billed charges,40% of total billed charges,4.38,11.65,
fluticasone nasal 50 mcg/inh Spr [FMC],2557593,CDM,250,RC,,,OUTPATIENT,16,UN,244.63,146.778,,207.94,85,,166.352,Percent of total billed charges,85% of total billed charges,122.32,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,122.32,50,,1.2,percent of total billed charges,50% of total billed charges,78.16,31.95,,7.032,percent of total billed charges,31.95% of total billed charges,78.16,31.95,,7.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,92.96,38,,74.368,percent of total billed charges,38% of total billed charges,97.85,40,,8.8,percent of total billed charges,40% of total billed charges,78.16,207.94,
fluticasone nasal 50 mcg/inh Spr [FMC],2557593,CDM,250,RC,,,OUTPATIENT,16,UN,277.1,166.26,,235.54,85,,188.432,Percent of total billed charges,85% of total billed charges,138.55,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,138.55,50,,1.6,percent of total billed charges,50% of total billed charges,88.53,31.95,,16.008,percent of total billed charges,31.95% of total billed charges,88.53,31.95,,16.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,105.3,38,,84.24,percent of total billed charges,38% of total billed charges,110.84,40,,20.04,percent of total billed charges,40% of total billed charges,88.53,235.54,
fluticasone nasal 50 mcg/inh Spr [FMC],2557593,CDM,250,RC,,,OUTPATIENT,16,UN,277.1,166.26,,235.54,85,,188.432,Percent of total billed charges,85% of total billed charges,138.55,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,138.55,50,,1.6,percent of total billed charges,50% of total billed charges,88.53,31.95,,2.752,percent of total billed charges,31.95% of total billed charges,88.53,31.95,,2.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,105.3,38,,84.24,percent of total billed charges,38% of total billed charges,110.84,40,,3.44,percent of total billed charges,40% of total billed charges,88.53,235.54,
fluticasone nasal 50 mcg/inh Spr [FMC],2557593,CDM,250,RC,,,OUTPATIENT,16,UN,274.04,164.424,,232.93,85,,186.344,Percent of total billed charges,85% of total billed charges,137.02,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,137.02,50,,1.6,percent of total billed charges,50% of total billed charges,87.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,87.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.14,38,,83.312,percent of total billed charges,38% of total billed charges,109.62,40,,0.96,percent of total billed charges,40% of total billed charges,87.56,232.93,
fludrocortisone 0.1 mg Tab [FMC],2557601,CDM,250,RC,,,OUTPATIENT,1,EA,3.43,2.058,,2.92,85,,2.336,Percent of total billed charges,85% of total billed charges,1.72,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.72,50,,1.6,percent of total billed charges,50% of total billed charges,1.1,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.1,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.3,38,,1.04,percent of total billed charges,38% of total billed charges,1.37,40,,0.96,percent of total billed charges,40% of total billed charges,1.1,2.92,
fludrocortisone 0.1 mg Tab [FMC],2557601,CDM,250,RC,,,OUTPATIENT,1,EA,5.19,3.114,,4.41,85,,3.528,Percent of total billed charges,85% of total billed charges,2.6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.6,50,,1.6,percent of total billed charges,50% of total billed charges,1.66,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.66,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.97,38,,1.576,percent of total billed charges,38% of total billed charges,2.08,40,,0.96,percent of total billed charges,40% of total billed charges,1.66,4.41,
fluocinonide Top 0.05% Crm [FMC],2557718,CDM,250,RC,,,OUTPATIENT,30,EA,296.08,177.648,,251.67,85,,201.336,Percent of total billed charges,85% of total billed charges,148.04,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,148.04,50,,1.2,percent of total billed charges,50% of total billed charges,94.6,31.95,,188.192,percent of total billed charges,31.95% of total billed charges,94.6,31.95,,3.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,112.51,38,,90.008,percent of total billed charges,38% of total billed charges,118.43,40,,171.056,percent of total billed charges,40% of total billed charges,94.6,251.67,
FLUoxetine 10 mg Cap [FMC],2557742,CDM,250,RC,,,OUTPATIENT,1,EA,7.86,4.716,,6.68,85,,5.344,Percent of total billed charges,85% of total billed charges,3.93,50,,1.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.93,50,,1.2,percent of total billed charges,50% of total billed charges,2.51,31.95,,188.192,percent of total billed charges,31.95% of total billed charges,2.51,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.99,38,,2.392,percent of total billed charges,38% of total billed charges,3.14,40,,171.056,percent of total billed charges,40% of total billed charges,2.51,6.68,
FLUoxetine 10 mg Cap [FMC],2557742,CDM,250,RC,,,OUTPATIENT,1,EA,8.36,5.016,,7.11,85,,5.688,Percent of total billed charges,85% of total billed charges,4.18,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.18,50,,1.2,percent of total billed charges,50% of total billed charges,2.67,31.95,,337.448,percent of total billed charges,31.95% of total billed charges,2.67,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.18,38,,2.544,percent of total billed charges,38% of total billed charges,3.34,40,,306.728,percent of total billed charges,40% of total billed charges,2.67,7.11,
FLUoxetine 10 mg Cap [FMC],2557742,CDM,250,RC,,,OUTPATIENT,1,EA,8.44,5.064,,7.17,85,,5.736,Percent of total billed charges,85% of total billed charges,4.22,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.22,50,,1.2,percent of total billed charges,50% of total billed charges,2.7,31.95,,306.848,percent of total billed charges,31.95% of total billed charges,2.7,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.21,38,,2.568,percent of total billed charges,38% of total billed charges,3.38,40,,278.912,percent of total billed charges,40% of total billed charges,2.7,7.17,
fluorescein ophthalmic 1 mg Test [FMC],2557783,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,1.2,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
fluorescein ophthalmic 1 mg Test [FMC],2557783,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,32.688,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
folic acid 1 mg Tab [FMC],2557874,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,32.688,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
folic acid 1 mg Tab [FMC],2557874,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,32.688,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
folic acid 1 mg Tab [FMC],2557874,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,32.688,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
folic acid 1 mg Tab [FMC],2557874,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,32.688,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
folic acid 1 mg Tab [FMC],2557874,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.392,percent of total billed charges,40% of total billed charges,0.96,2.55,
folic acid 1 mg Tab [FMC],2557874,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.328,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
folic acid 5 mg/mL Inj Sol [FMC],2557882,CDM,250,RC,,,OUTPATIENT,10,ML,104.13,62.478,,88.51,85,,70.808,Percent of total billed charges,85% of total billed charges,52.07,50,,3.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.07,50,,2.192,percent of total billed charges,50% of total billed charges,33.27,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,33.27,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.57,38,,31.656,percent of total billed charges,38% of total billed charges,41.65,40,,1.248,percent of total billed charges,40% of total billed charges,33.27,88.51,
folic acid 5 mg/mL Inj Sol [FMC],2557882,CDM,250,RC,,,OUTPATIENT,10,ML,191.82,115.092,,163.05,85,,130.44,Percent of total billed charges,85% of total billed charges,95.91,50,,2.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,95.91,50,,3.328,percent of total billed charges,50% of total billed charges,61.29,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,61.29,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,72.89,38,,58.312,percent of total billed charges,38% of total billed charges,76.73,40,,0.96,percent of total billed charges,40% of total billed charges,61.29,163.05,
folic acid 5 mg/mL Inj Sol [FMC],2557882,CDM,250,RC,,,OUTPATIENT,10,ML,142.19,85.314,,120.86,85,,96.688,Percent of total billed charges,85% of total billed charges,71.1,50,,6.232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,71.1,50,,2.992,percent of total billed charges,50% of total billed charges,45.43,31.95,,3.72,percent of total billed charges,31.95% of total billed charges,45.43,31.95,,3.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.03,38,,43.224,percent of total billed charges,38% of total billed charges,56.88,40,,4.656,percent of total billed charges,40% of total billed charges,45.43,120.86,
multivitamin Vitamin B Complex with Folic Acid Tab [FMC],2557890,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
multivitamin Vitamin B Complex with Folic Acid Tab [FMC],2557890,CDM,250,RC,,,OUTPATIENT,1,EA,4.38,2.628,,3.72,85,,2.976,Percent of total billed charges,85% of total billed charges,2.19,50,,6.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.19,50,,1.2,percent of total billed charges,50% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.66,38,,1.328,percent of total billed charges,38% of total billed charges,1.75,40,,0.96,percent of total billed charges,40% of total billed charges,1.4,3.72,
multivitamin Vitamin B Complex with Folic Acid Tab [FMC],2557890,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.76,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cefTAZidime 1 g Inj  [FMC],2557908,CDM,250,RC,J0713,HCPCS,OUTPATIENT,1,EA,23.21,13.926,,19.73,85,,15.784,Percent of total billed charges,85% of total billed charges,2.68,136.6,,6.296,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.68,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.16,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,7.42,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.82,38,,7.056,percent of total billed charges,38% of total billed charges,7.42,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,2.68,19.73,
cefTAZidime 1 g Inj  [FMC],2557908,CDM,250,RC,J0713,HCPCS,OUTPATIENT,1,EA,16.63,9.978,,14.14,85,,11.312,Percent of total billed charges,85% of total billed charges,2.68,136.6,,12.448,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.68,136.6,,3.576,fee schedule,136.60% of BCBS custom fee schedule,5.85,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,5.31,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.32,38,,5.056,percent of total billed charges,38% of total billed charges,5.31,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,2.68,14.14,
cefTAZidime 1 g Inj  [FMC],2557908,CDM,250,RC,J0713,HCPCS,OUTPATIENT,1,EA,17.55,10.53,,14.92,85,,11.936,Percent of total billed charges,85% of total billed charges,2.68,136.6,,7.28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.68,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,6.17,35.15,,1.536,fee schedule,35.15% of LA custom fee schedule,5.61,31.95,,1.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.67,38,,5.336,percent of total billed charges,38% of total billed charges,5.61,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,2.68,14.92,
cefTAZidime 1 g Inj  [FMC],2557908,CDM,250,RC,J0713,HCPCS,OUTPATIENT,1,EA,20.28,12.168,,17.24,85,,13.792,Percent of total billed charges,85% of total billed charges,2.68,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.68,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,7.13,35.15,,1.536,fee schedule,35.15% of LA custom fee schedule,6.48,31.95,,1.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.71,38,,6.168,percent of total billed charges,38% of total billed charges,6.48,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,2.68,17.24,
alendronate 70 mg Tab [FMC],2557924,CDM,250,RC,,,OUTPATIENT,1,EA,66.59,39.954,,56.6,85,,45.28,Percent of total billed charges,85% of total billed charges,33.3,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.3,50,,2.4,percent of total billed charges,50% of total billed charges,21.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,21.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.3,38,,20.24,percent of total billed charges,38% of total billed charges,26.64,40,,0.96,percent of total billed charges,40% of total billed charges,21.28,56.6,
alendronate 70 mg Tab [FMC],2557924,CDM,250,RC,,,OUTPATIENT,1,EA,117.66,70.596,,100.01,85,,80.008,Percent of total billed charges,85% of total billed charges,58.83,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,58.83,50,,3.568,percent of total billed charges,50% of total billed charges,37.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,37.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.71,38,,35.768,percent of total billed charges,38% of total billed charges,47.06,40,,0.96,percent of total billed charges,40% of total billed charges,37.59,100.01,
furosemide 10 mg/mL Inj 10ml Sol [FMC],2557940,CDM,250,RC,J1940,HCPCS,OUTPATIENT,10,ML,22.76,13.656,,19.35,85,,15.48,Percent of total billed charges,85% of total billed charges,0.87,136.6,,1.216,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,3.568,fee schedule,136.60% of BCBS custom fee schedule,8,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,104.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.65,38,,6.92,percent of total billed charges,38% of total billed charges,7.27,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.87,104.8,
furosemide 10 mg/mL Inj 10ml Sol [FMC],2557940,CDM,250,RC,J1940,HCPCS,OUTPATIENT,10,ML,91.1,54.66,,77.44,85,,61.952,Percent of total billed charges,85% of total billed charges,0.87,136.6,,2.464,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,1.624,fee schedule,136.60% of BCBS custom fee schedule,32.02,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.62,38,,27.696,percent of total billed charges,38% of total billed charges,29.11,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.87,77.44,
furosemide 10 mg/mL Inj 10ml Sol [FMC],2557940,CDM,250,RC,J1940,HCPCS,OUTPATIENT,10,ML,12.09,7.254,,10.28,85,,8.224,Percent of total billed charges,85% of total billed charges,0.87,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.25,35.15,,28.392,percent of total billed charges,35.15% of total billed charges,2.56,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.59,38,,3.672,percent of total billed charges,38% of total billed charges,3.86,31.95,,25.808,percent of total billed charges,31.95% of total billed charges,0.87,10.28,
furosemide 10 mg/mL Inj 10ml Sol [FMC],2557940,CDM,250,RC,J1940,HCPCS,OUTPATIENT,10,ML,15.56,9.336,,13.23,85,,10.584,Percent of total billed charges,85% of total billed charges,0.87,136.6,,343.984,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,5.47,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,26.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.91,38,,4.728,percent of total billed charges,38% of total billed charges,4.97,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.87,26.84,
furosemide 10 mg/mL Inj 10ml Sol [FMC],2557940,CDM,250,RC,J1940,HCPCS,OUTPATIENT,10,ML,13.2,7.92,,11.22,85,,8.976,Percent of total billed charges,85% of total billed charges,0.87,136.6,,11.832,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,2.184,fee schedule,136.60% of BCBS custom fee schedule,4.64,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.02,38,,4.016,percent of total billed charges,38% of total billed charges,4.22,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.87,11.22,
furosemide 10 mg/mL Inj 10ml Sol [FMC],2557940,CDM,250,RC,J1940,HCPCS,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.87,136.6,,15.784,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,2.16,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,6.568,percent of total billed charges,35.15% of total billed charges,5.93,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,5.968,percent of total billed charges,31.95% of total billed charges,0.87,10.2,
furosemide 10 mg/mL Inj 2ml Sol [FMC],2557965,CDM,250,RC,J1940,HCPCS,OUTPATIENT,2,ML,17.3,10.38,,14.71,85,,11.768,Percent of total billed charges,85% of total billed charges,0.87,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,2.68,fee schedule,136.60% of BCBS custom fee schedule,6.08,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,9.49,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.57,38,,5.256,percent of total billed charges,38% of total billed charges,5.53,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.87,14.71,
furosemide 10 mg/mL Inj 2ml Sol [FMC],2557965,CDM,250,RC,J1940,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.87,136.6,,1.528,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,2.632,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.87,11.5,
furosemide 10 mg/mL Inj 2ml Sol [FMC],2557965,CDM,250,RC,J1940,HCPCS,OUTPATIENT,2,ML,24.1,14.46,,20.49,85,,16.392,Percent of total billed charges,85% of total billed charges,0.87,136.6,,1.384,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.47,35.15,,1.472,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,1.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.16,38,,7.328,percent of total billed charges,38% of total billed charges,7.7,31.95,,1.84,percent of total billed charges,31.95% of total billed charges,0.87,20.49,
furosemide 10 mg/mL Inj 2ml Sol [FMC],2557965,CDM,250,RC,J1940,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.87,136.6,,1.384,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.808,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.016,percent of total billed charges,31.95% of total billed charges,0.87,11.5,
furosemide 10 mg/mL Inj 2ml Sol [FMC],2557965,CDM,250,RC,J1940,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.87,136.6,,1.288,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,4.112,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.904,percent of total billed charges,35.15% of total billed charges,9.35,31.95,,0.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,0.87,10.2,
furosemide 20 mg Tab [FMC],2557973,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.568,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 20 mg Tab [FMC],2557973,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.744,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.344,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 20 mg Tab [FMC],2557973,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.568,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 20 mg Tab [FMC],2557973,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.744,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 20 mg Tab [FMC],2557973,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,16.768,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12.968,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 10 mg/mL Inj 4ml Sol [FMC],2557981,CDM,250,RC,J1940,HCPCS,OUTPATIENT,4,ML,12.25,7.35,,10.41,85,,8.328,Percent of total billed charges,85% of total billed charges,0.87,136.6,,71.824,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,20.808,fee schedule,136.60% of BCBS custom fee schedule,4.31,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,10.36,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.66,38,,3.728,percent of total billed charges,38% of total billed charges,3.91,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.87,10.41,
furosemide 10 mg/mL Inj 4ml Sol [FMC],2557981,CDM,250,RC,J1940,HCPCS,OUTPATIENT,4,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.87,136.6,,74.04,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,12.712,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,7.99,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,0.87,10.2,
furosemide 10 mg/mL Inj 4ml Sol [FMC],2557981,CDM,250,RC,J1940,HCPCS,OUTPATIENT,4,ML,13.77,8.262,,11.7,85,,9.36,Percent of total billed charges,85% of total billed charges,0.87,136.6,,68.304,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,19.88,fee schedule,136.60% of BCBS custom fee schedule,4.84,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,19.81,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.23,38,,4.184,percent of total billed charges,38% of total billed charges,4.4,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,0.87,19.81,
furosemide 10 mg/mL Inj 4ml Sol [FMC],2557981,CDM,250,RC,J1940,HCPCS,OUTPATIENT,4,ML,13.13,7.878,,11.16,85,,8.928,Percent of total billed charges,85% of total billed charges,0.87,136.6,,74.04,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,1.48,fee schedule,136.60% of BCBS custom fee schedule,4.62,35.15,,28.104,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,28.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.99,38,,3.992,percent of total billed charges,38% of total billed charges,4.2,31.95,,35.184,percent of total billed charges,31.95% of total billed charges,0.87,11.16,
furosemide 10 mg/mL Inj 4ml Sol [FMC],2557981,CDM,250,RC,J1940,HCPCS,OUTPATIENT,4,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.87,136.6,,25.824,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,2.808,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,31.296,percent of total billed charges,35.15% of total billed charges,9.9,31.95,,31.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,39.184,percent of total billed charges,31.95% of total billed charges,0.87,10.2,
furosemide 10 mg/mL Inj 4ml Sol [FMC],2557981,CDM,250,RC,J1940,HCPCS,OUTPATIENT,4,ML,13.65,8.19,,11.6,85,,9.28,Percent of total billed charges,85% of total billed charges,0.87,136.6,,57.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,4.112,fee schedule,136.60% of BCBS custom fee schedule,4.8,35.15,,32.8,percent of total billed charges,35.15% of total billed charges,9.9,31.95,,32.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.19,38,,4.152,percent of total billed charges,38% of total billed charges,4.36,31.95,,41.072,percent of total billed charges,31.95% of total billed charges,0.87,11.6,
furosemide 10 mg/mL Inj 4ml Sol [FMC],2557981,CDM,250,RC,J1940,HCPCS,OUTPATIENT,4,ML,12.25,7.35,,10.41,85,,8.328,Percent of total billed charges,85% of total billed charges,0.87,136.6,,5.552,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,4.928,fee schedule,136.60% of BCBS custom fee schedule,4.31,35.15,,2.808,percent of total billed charges,35.15% of total billed charges,27.16,31.95,,2.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.66,38,,3.728,percent of total billed charges,38% of total billed charges,3.91,31.95,,3.52,percent of total billed charges,31.95% of total billed charges,0.87,27.16,
furosemide 40 mg Tab [FMC],2557999,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.728,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,170.624,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.096,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.624,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 40 mg Tab [FMC],2557999,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,40.176,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 40 mg Tab [FMC],2557999,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,170.728,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 40 mg Tab [FMC],2557999,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.616,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 40 mg Tab [FMC],2557999,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.376,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 40 mg Tab [FMC],2557999,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.592,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.36,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.208,percent of total billed charges,40% of total billed charges,0.96,2.55,
furosemide 40 mg Tab [FMC],2557999,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.592,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.88,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.328,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.416,percent of total billed charges,40% of total billed charges,0.96,2.55,
gemfibrozil 600 mg Tab UD[FMC],2558062,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12.48,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.4,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.008,percent of total billed charges,40% of total billed charges,0.96,2.55,
gemfibrozil 600 mg Tab UD[FMC],2558062,CDM,250,RC,,,OUTPATIENT,1,EA,7.52,4.512,,6.39,85,,5.112,Percent of total billed charges,85% of total billed charges,3.76,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.76,50,,40.624,percent of total billed charges,50% of total billed charges,2.4,31.95,,4.328,percent of total billed charges,31.95% of total billed charges,2.4,31.95,,4.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.86,38,,2.288,percent of total billed charges,38% of total billed charges,3.01,40,,5.416,percent of total billed charges,40% of total billed charges,2.4,6.39,
gemfibrozil 600 mg Tab,2558062,CDM,250,RC,,,OUTPATIENT,1,EA,3.78,2.268,,3.21,85,,2.568,Percent of total billed charges,85% of total billed charges,1.89,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.89,50,,4.8,percent of total billed charges,50% of total billed charges,1.21,31.95,,3.648,percent of total billed charges,31.95% of total billed charges,1.21,31.95,,3.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.44,38,,1.152,percent of total billed charges,38% of total billed charges,1.51,40,,4.568,percent of total billed charges,40% of total billed charges,1.21,3.21,
simethicone 40 mg/0.6 mL Liq [FMC],2558096,CDM,250,RC,,,OUTPATIENT,30,ML,19.31,11.586,,16.41,85,,13.128,Percent of total billed charges,85% of total billed charges,9.66,50,,2.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.66,50,,2.968,percent of total billed charges,50% of total billed charges,6.17,31.95,,2.52,percent of total billed charges,31.95% of total billed charges,6.17,31.95,,2.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.34,38,,5.872,percent of total billed charges,38% of total billed charges,7.72,40,,3.16,percent of total billed charges,40% of total billed charges,6.17,16.41,
simethicone 40 mg/0.6 mL Liq [FMC],2558096,CDM,250,RC,,,OUTPATIENT,30,ML,11.38,6.828,,9.67,85,,7.736,Percent of total billed charges,85% of total billed charges,5.69,50,,2.896,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.69,50,,1.2,percent of total billed charges,50% of total billed charges,3.64,31.95,,1.952,percent of total billed charges,31.95% of total billed charges,3.64,31.95,,1.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.32,38,,3.456,percent of total billed charges,38% of total billed charges,4.55,40,,2.44,percent of total billed charges,40% of total billed charges,3.64,9.67,
simethicone 40 mg/0.6 mL Liq [FMC],2558096,CDM,250,RC,,,OUTPATIENT,30,ML,22.91,13.746,,19.47,85,,15.576,Percent of total billed charges,85% of total billed charges,11.46,50,,2.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.46,50,,1.2,percent of total billed charges,50% of total billed charges,7.32,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,7.32,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.71,38,,6.968,percent of total billed charges,38% of total billed charges,9.16,40,,4.248,percent of total billed charges,40% of total billed charges,7.32,19.47,
simethicone 40 mg/0.6 mL Liq [FMC],2558096,CDM,250,RC,,,OUTPATIENT,30,ML,29.57,17.742,,25.13,85,,20.104,Percent of total billed charges,85% of total billed charges,14.79,50,,2.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.79,50,,1.2,percent of total billed charges,50% of total billed charges,9.45,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,9.45,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.24,38,,8.992,percent of total billed charges,38% of total billed charges,11.83,40,,1.736,percent of total billed charges,40% of total billed charges,9.45,25.13,
simethicone 40 mg/0.6 mL Liq [FMC],2558096,CDM,250,RC,,,OUTPATIENT,30,ML,7.25,4.35,,6.16,85,,4.928,Percent of total billed charges,85% of total billed charges,3.63,50,,2.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.63,50,,1.2,percent of total billed charges,50% of total billed charges,2.32,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,2.32,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.76,38,,2.208,percent of total billed charges,38% of total billed charges,2.9,40,,4.248,percent of total billed charges,40% of total billed charges,2.32,6.16,
simethicone 40 mg/0.6 mL Liq [FMC],2558096,CDM,250,RC,,,OUTPATIENT,30,ML,28.93,17.358,,24.59,85,,19.672,Percent of total billed charges,85% of total billed charges,14.47,50,,3.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.47,50,,1.648,percent of total billed charges,50% of total billed charges,9.24,31.95,,15.704,percent of total billed charges,31.95% of total billed charges,9.24,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.99,38,,8.792,percent of total billed charges,38% of total billed charges,11.57,40,,14.272,percent of total billed charges,40% of total billed charges,9.24,24.59,
oxymetazoline Nasal 0.05% Spry [FMC],2558112,CDM,250,RC,,,OUTPATIENT,15,UN,6.66,3.996,,5.66,85,,4.528,Percent of total billed charges,85% of total billed charges,3.33,50,,2.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.33,50,,1.2,percent of total billed charges,50% of total billed charges,2.13,31.95,,48.504,percent of total billed charges,31.95% of total billed charges,2.13,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.53,38,,2.024,percent of total billed charges,38% of total billed charges,2.66,40,,44.088,percent of total billed charges,40% of total billed charges,2.13,5.66,
oxymetazoline Nasal 0.05% Spry [FMC],2558112,CDM,250,RC,,,OUTPATIENT,15,UN,19.32,11.592,,16.42,85,,13.136,Percent of total billed charges,85% of total billed charges,9.66,50,,4.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.66,50,,6.176,percent of total billed charges,50% of total billed charges,6.17,31.95,,13.16,percent of total billed charges,31.95% of total billed charges,6.17,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.34,38,,5.872,percent of total billed charges,38% of total billed charges,7.73,40,,11.96,percent of total billed charges,40% of total billed charges,6.17,16.42,
oxymetazoline Nasal 0.05% Spry [FMC],2558112,CDM,250,RC,,,OUTPATIENT,15,UN,33.44,20.064,,28.42,85,,22.736,Percent of total billed charges,85% of total billed charges,16.72,50,,1.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.72,50,,3.224,percent of total billed charges,50% of total billed charges,10.68,31.95,,10.28,percent of total billed charges,31.95% of total billed charges,10.68,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.71,38,,10.168,percent of total billed charges,38% of total billed charges,13.38,40,,9.344,percent of total billed charges,40% of total billed charges,10.68,28.42,
oxymetazoline Nasal 0.05% Spry [FMC],2558112,CDM,250,RC,,,OUTPATIENT,15,UN,6.08,3.648,,5.17,85,,4.136,Percent of total billed charges,85% of total billed charges,3.04,50,,2.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.04,50,,1.2,percent of total billed charges,50% of total billed charges,1.94,31.95,,16.448,percent of total billed charges,31.95% of total billed charges,1.94,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.31,38,,1.848,percent of total billed charges,38% of total billed charges,2.43,40,,14.952,percent of total billed charges,40% of total billed charges,1.94,5.17,
oxymetazoline Nasal 0.05% Spry [FMC],2558112,CDM,250,RC,,,OUTPATIENT,15,UN,15.02,9.012,,12.77,85,,10.216,Percent of total billed charges,85% of total billed charges,7.51,50,,1.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.51,50,,6.176,percent of total billed charges,50% of total billed charges,4.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.71,38,,4.568,percent of total billed charges,38% of total billed charges,6.01,40,,0.96,percent of total billed charges,40% of total billed charges,4.8,12.77,
oxymetazoline Nasal 0.05% Spry [FMC],2558112,CDM,250,RC,,,OUTPATIENT,15,UN,7.77,4.662,,6.6,85,,5.28,Percent of total billed charges,85% of total billed charges,3.89,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.89,50,,16.936,percent of total billed charges,50% of total billed charges,2.48,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.48,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.95,38,,2.36,percent of total billed charges,38% of total billed charges,3.11,40,,0.96,percent of total billed charges,40% of total billed charges,2.48,6.6,
gentamicin 40 mg/mL Inj Sol [FMC],2558138,CDM,250,RC,J1580,HCPCS,OUTPATIENT,2,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.38,136.6,,1.72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.38,136.6,,17,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,4.38,30.6,
gentamicin 40 mg/mL Inj Sol [FMC],2558138,CDM,250,RC,J1580,HCPCS,OUTPATIENT,2,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.38,136.6,,1.72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.38,136.6,,16.936,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,5.936,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,5.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,7.424,Fee Schedule,31.95% of LA custom fee schedule,4.38,30.6,
gentamicin 40 mg/mL Inj Sol [FMC],2558138,CDM,250,RC,J1580,HCPCS,OUTPATIENT,2,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.38,136.6,,1.752,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.38,136.6,,16.936,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,18.816,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,18.816,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,23.552,Fee Schedule,31.95% of LA custom fee schedule,4.38,30.6,
gentamicin 80 mg/100 mL-NS IV Sol [FMC],2558146,CDM,250,RC,J1580,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.38,136.6,,2.44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.38,136.6,,5.408,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,10.264,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,10.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,12.848,Fee Schedule,31.95% of LA custom fee schedule,4.38,30.6,
gentamicin Ophth 0.3% Sol [FMC],2558211,CDM,250,RC,,,OUTPATIENT,5,EA,139.26,83.556,,118.37,85,,94.696,Percent of total billed charges,85% of total billed charges,69.63,50,,2.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,69.63,50,,1.2,percent of total billed charges,50% of total billed charges,44.49,31.95,,18.832,percent of total billed charges,31.95% of total billed charges,44.49,31.95,,18.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,52.92,38,,42.336,percent of total billed charges,38% of total billed charges,55.7,40,,23.576,percent of total billed charges,40% of total billed charges,44.49,118.37,
gentamicin Ophth 0.3% Sol [FMC],2558211,CDM,250,RC,,,OUTPATIENT,5,EA,17.23,10.338,,14.65,85,,11.72,Percent of total billed charges,85% of total billed charges,8.62,50,,2.824,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.62,50,,1.2,percent of total billed charges,50% of total billed charges,5.5,31.95,,18.816,percent of total billed charges,31.95% of total billed charges,5.5,31.95,,18.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.55,38,,5.24,percent of total billed charges,38% of total billed charges,6.89,40,,23.552,percent of total billed charges,40% of total billed charges,5.5,14.65,
gentamicin Ophth 0.3% Sol [FMC],2558211,CDM,250,RC,,,OUTPATIENT,5,EA,70.53,42.318,,59.95,85,,47.96,Percent of total billed charges,85% of total billed charges,35.27,50,,58.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.27,50,,3.744,percent of total billed charges,50% of total billed charges,22.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,22.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.8,38,,21.44,percent of total billed charges,38% of total billed charges,28.21,40,,0.96,percent of total billed charges,40% of total billed charges,22.53,59.95,
ziprasidone 20 mg Cap UD [FMC],2558237,CDM,250,RC,,,OUTPATIENT,1,EA,27.51,16.506,,23.38,85,,18.704,Percent of total billed charges,85% of total billed charges,13.76,50,,20.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.76,50,,2.192,percent of total billed charges,50% of total billed charges,8.79,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,8.79,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.45,38,,8.36,percent of total billed charges,38% of total billed charges,11,40,,0.96,percent of total billed charges,40% of total billed charges,8.79,23.38,
ziprasidone 20 mg Cap UD [FMC],2558237,CDM,250,RC,,,OUTPATIENT,1,EA,62.63,37.578,,53.24,85,,42.592,Percent of total billed charges,85% of total billed charges,31.32,50,,291.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.32,50,,2.992,percent of total billed charges,50% of total billed charges,20.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,20.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.8,38,,19.04,percent of total billed charges,38% of total billed charges,25.05,40,,0.96,percent of total billed charges,40% of total billed charges,20.01,53.24,
ziprasidone 20 mg Cap UD [FMC],2558237,CDM,250,RC,,,OUTPATIENT,1,EA,10.76,6.456,,9.15,85,,7.32,Percent of total billed charges,85% of total billed charges,5.38,50,,2.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.38,50,,2.232,percent of total billed charges,50% of total billed charges,3.44,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.44,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.09,38,,3.272,percent of total billed charges,38% of total billed charges,4.3,40,,0.96,percent of total billed charges,40% of total billed charges,3.44,9.15,
ziprasidone 20 mg Cap UD [FMC],2558237,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
glipiZIDE 5 mg Tab [FMC],2558286,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
glipiZIDE 5 mg Tab [FMC],2558286,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.584,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
glucagon recombinant 1 mg REC [FMC],2558302,CDM,250,RC,J1610,HCPCS,OUTPATIENT,1,EA,669.24,401.544,,568.85,85,,455.08,Percent of total billed charges,85% of total billed charges,281.74,136.6,,5.744,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,281.74,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,235.24,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,4.14,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,254.31,38,,203.448,percent of total billed charges,38% of total billed charges,213.82,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,4.14,568.85,
glucagon recombinant 1 mg REC [FMC],2558302,CDM,250,RC,J1610,HCPCS,OUTPATIENT,1,EA,669.24,401.544,,568.85,85,,455.08,Percent of total billed charges,85% of total billed charges,281.74,136.6,,5.744,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,281.74,136.6,,1.576,fee schedule,136.60% of BCBS custom fee schedule,235.24,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,7.99,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,254.31,38,,203.448,percent of total billed charges,38% of total billed charges,213.82,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,7.99,568.85,
glucagon recombinant 1 mg REC [FMC],2558302,CDM,250,RC,J1610,HCPCS,OUTPATIENT,1,EA,1200.03,720.018,,1020.03,85,,816.024,Percent of total billed charges,85% of total billed charges,281.74,136.6,,2.776,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,281.74,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,421.81,35.15,,3.952,percent of total billed charges,35.15% of total billed charges,7.99,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,456.01,38,,364.808,percent of total billed charges,38% of total billed charges,383.41,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,7.99,1020.03,
glucagon recombinant 1 mg REC [FMC],2558302,CDM,250,RC,J1610,HCPCS,OUTPATIENT,1,EA,1091.22,654.732,,927.54,85,,742.032,Percent of total billed charges,85% of total billed charges,281.74,136.6,,2.776,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,281.74,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,383.56,35.15,,5.672,percent of total billed charges,35.15% of total billed charges,5.11,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,414.66,38,,331.728,percent of total billed charges,38% of total billed charges,348.64,31.95,,5.152,percent of total billed charges,31.95% of total billed charges,5.11,927.54,
glipiZIDE 2.5 mg ER Tab [FMC],2558328,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,335.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.84,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
glipiZIDE 2.5 mg ER Tab [FMC],2558328,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1249.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.552,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.136,percent of total billed charges,40% of total billed charges,0.96,2.55,
glipiZIDE 2.5 mg ER Tab [FMC],2558328,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,124.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
glipiZIDE 5 mg ER Tab [FMC],2558351,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,420.736,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.24,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.168,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.064,percent of total billed charges,40% of total billed charges,0.96,2.55,
glipiZIDE 5 mg ER Tab [FMC],2558351,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,32.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.352,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.056,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
glipiZIDE 5 mg ER Tab [FMC],2558351,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,36.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.656,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,10.592,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg ER Tab [FMC],2558377,CDM,250,RC,,,OUTPATIENT,1,EA,4.35,2.61,,3.7,85,,2.96,Percent of total billed charges,85% of total billed charges,2.18,50,,36.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.18,50,,1.2,percent of total billed charges,50% of total billed charges,1.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.65,38,,1.32,percent of total billed charges,38% of total billed charges,1.74,40,,0.96,percent of total billed charges,40% of total billed charges,1.39,3.7,
metFORMIN 500 mg ER Tab [FMC] -  - Inpatient - FMC HOSP - Active - 00904-5794-61,2558377,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,13.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12.984,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg ER Tab [FMC],2558377,CDM,250,RC,,,OUTPATIENT,1,EA,3.89,2.334,,3.31,85,,2.648,Percent of total billed charges,85% of total billed charges,1.95,50,,7.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.95,50,,22.624,percent of total billed charges,50% of total billed charges,1.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.48,38,,1.184,percent of total billed charges,38% of total billed charges,1.56,40,,0.96,percent of total billed charges,40% of total billed charges,1.24,3.31,
metFORMIN 500 mg ER Tab [FMC],2558377,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,8.032,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,13.64,percent of total billed charges,50% of total billed charges,0.96,31.95,,33.056,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,33.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,41.384,percent of total billed charges,40% of total billed charges,0.96,2.55,
glucose 31 gm Liq [FMC],2558385,CDM,250,RC,,,OUTPATIENT,31,EA,14.55,8.73,,12.37,85,,9.896,Percent of total billed charges,85% of total billed charges,7.28,50,,8.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.28,50,,7.8,percent of total billed charges,50% of total billed charges,4.65,31.95,,33.224,percent of total billed charges,31.95% of total billed charges,4.65,31.95,,33.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.53,38,,4.424,percent of total billed charges,38% of total billed charges,5.82,40,,41.592,percent of total billed charges,40% of total billed charges,4.65,12.37,
glyBURIDE 5 mg Tab [FMC],2558401,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,8.584,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,27.952,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.824,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.024,percent of total billed charges,40% of total billed charges,0.96,2.55,
glyBURIDE 5 mg Tab [FMC],2558401,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.696,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.04,percent of total billed charges,40% of total billed charges,0.96,2.55,
glyBURIDE 5 mg Tab [FMC],2558401,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
glyBURIDE 5 mg Tab [FMC],2558401,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
glyBURIDE 5 mg Tab [FMC],2558401,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,21.064,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
glycerin PEDIATRIC Supp [FMC],2558419,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,7.752,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
glycerin PEDIATRIC Supp [FMC],2558419,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,4.8,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
guaiFENesin 200 mg/10 mL Liq UD [FMC],2558518,CDM,250,RC,,,OUTPATIENT,10,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.536,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup [FMC],2558526,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.408,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup [FMC],2558526,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.68,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 120 mL [FMC],2558526,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,13.36,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
haloperidol decanoate 50 mg/mL Sol [FMC],2558559,CDM,250,RC,J1631,HCPCS,OUTPATIENT,1,ML,100.97,60.582,,85.82,85,,68.656,Percent of total billed charges,85% of total billed charges,12.08,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,12.08,136.6,,12.168,fee schedule,136.60% of BCBS custom fee schedule,35.49,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.37,38,,30.696,percent of total billed charges,38% of total billed charges,32.26,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,4.47,85.82,
haloperidol 0.5 mg Tab [FMC],2558583,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
haloperidol 0.5 mg Tab [FMC],2558583,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
haloperidol 5 mg/mL Sol [FMC],2558591,CDM,250,RC,J1630,HCPCS,OUTPATIENT,1,ML,23.36,14.016,,19.86,85,,15.888,Percent of total billed charges,85% of total billed charges,1.86,136.6,,2.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.86,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.21,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,4.79,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.88,38,,7.104,percent of total billed charges,38% of total billed charges,7.46,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.86,19.86,
haloperidol 5 mg/mL Sol [FMC],2558591,CDM,250,RC,J1630,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.86,136.6,,22.816,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.86,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,4.79,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.86,10.2,
haloperidol 5 mg/mL Sol [FMC],2558591,CDM,250,RC,J1630,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.86,136.6,,22.752,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.86,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,10.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.86,10.22,
haloperidol 5 mg Tab UD [FMC],2558617,CDM,250,RC,,,OUTPATIENT,1,EA,5.76,3.456,,4.9,85,,3.92,Percent of total billed charges,85% of total billed charges,2.88,50,,22.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.88,50,,1.6,percent of total billed charges,50% of total billed charges,1.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.19,38,,1.752,percent of total billed charges,38% of total billed charges,2.3,40,,0.96,percent of total billed charges,40% of total billed charges,1.84,4.9,
haloperidol 5 mg Tab UD [FMC],2558617,CDM,250,RC,,,OUTPATIENT,1,EA,3.17,1.902,,2.69,85,,2.152,Percent of total billed charges,85% of total billed charges,1.59,50,,17.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.59,50,,1.6,percent of total billed charges,50% of total billed charges,1.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.2,38,,0.96,percent of total billed charges,38% of total billed charges,1.27,40,,0.96,percent of total billed charges,40% of total billed charges,1.01,2.69,
haloperidol 5 mg Tab UD [FMC],2558617,CDM,250,RC,,,OUTPATIENT,1,EA,3.55,2.13,,3.02,85,,2.416,Percent of total billed charges,85% of total billed charges,1.78,50,,21.84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.78,50,,1.6,percent of total billed charges,50% of total billed charges,1.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.35,38,,1.08,percent of total billed charges,38% of total billed charges,1.42,40,,0.96,percent of total billed charges,40% of total billed charges,1.13,3.02,
hydrochlorothiazide 25 mg Tab [FMC],2558625,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,22.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,26.144,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrochlorothiazide 25 mg Tab [FMC],2558625,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,22.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,26.144,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrochlorothiazide 25 mg Tab [FMC],2558625,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,135.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,26.144,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrochlorothiazide 25 mg Tab [FMC],2558625,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,133.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,26.152,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrochlorothiazide 25 mg Tab [FMC],2558625,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,135.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,26.144,percent of total billed charges,40% of total billed charges,0.96,2.55,
ferrous fumarate-folic acid 324 mg-1 mg Tab [FMC],2558658,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,26.32,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,23.928,percent of total billed charges,40% of total billed charges,0.96,2.55,
heparin 5000 units/mL Inj Sol ORANGE cap 1mL vial [FMC],2558708,CDM,250,RC,J1644,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.42,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,77.68,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,8.688,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,70.608,Fee Schedule,31.95% of LA custom fee schedule,0.42,10.2,
heparin 5000 units/mL Inj Sol ORANGE cap 1mL vial [FMC],2558708,CDM,250,RC,J1644,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.42,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,161.08,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,9.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,146.416,Fee Schedule,31.95% of LA custom fee schedule,0.42,10.2,
heparin 5000 units/mL Inj Sol ORANGE cap 1mL vial [FMC],2558708,CDM,250,RC,J1644,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.42,136.6,,4.352,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,77.68,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,70.608,Fee Schedule,31.95% of LA custom fee schedule,0.42,10.2,
heparin 5000 units/mL Inj Sol ORANGE cap 1mL vial [FMC],2558708,CDM,250,RC,J1644,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.42,136.6,,3.544,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,1.24,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,9.136,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,8.304,Fee Schedule,31.95% of LA custom fee schedule,0.42,10.2,
heparin 5000 units/mL Inj Sol ORANGE cap 1mL vial [FMC],2558708,CDM,250,RC,J1644,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.42,136.6,,3.816,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,1.224,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,11.04,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,10.04,Fee Schedule,31.95% of LA custom fee schedule,0.42,10.2,
heparin 5000 units/mL Inj Sol ORANGE cap 1mL vial [FMC],2558708,CDM,250,RC,J1644,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.42,136.6,,3.624,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,1.368,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.42,10.2,
"Normal Saline Flush Syringe, 0.9% 10ml [FMC]",2558724,CDM,250,RC,,,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,280.832,percent of total billed charges,50% of total billed charges,3.83,31.95,,2.128,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,2.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,2.664,percent of total billed charges,40% of total billed charges,3.83,10.2,
"Normal Saline Flush Syringe, 0.9% 10ml [FMC]",2558724,CDM,250,RC,,,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,3.36,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,1.752,percent of total billed charges,40% of total billed charges,3.83,10.2,
insulin lispro protamine 75% suspension and insulin lispro 25%  injection [FMC,2558815,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,67.76,40.656,,57.6,85,,46.08,Percent of total billed charges,85% of total billed charges,0.76,136.6,,2.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,4.96,fee schedule,136.60% of BCBS custom fee schedule,23.82,35.15,,2.128,fee schedule,35.15% of LA custom fee schedule,21.65,31.95,,2.128,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.75,38,,20.6,percent of total billed charges,38% of total billed charges,21.65,31.95,,2.664,Fee Schedule,31.95% of LA custom fee schedule,0.76,57.6,
insulin lispro 100 units/mL SubQ 10 mL Inj [FMC],2558831,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,107.13,64.278,,91.06,85,,72.848,Percent of total billed charges,85% of total billed charges,0.76,136.6,,2.272,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,5.312,fee schedule,136.60% of BCBS custom fee schedule,37.66,35.15,,1.912,fee schedule,35.15% of LA custom fee schedule,34.23,31.95,,1.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,40.71,38,,32.568,percent of total billed charges,38% of total billed charges,34.23,31.95,,2.392,Fee Schedule,31.95% of LA custom fee schedule,0.76,91.06,
insulin lispro 100 units/mL SubQ 10 mL Inj [FMC],2558831,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,32.14,19.284,,27.32,85,,21.856,Percent of total billed charges,85% of total billed charges,0.76,136.6,,1.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,2.552,fee schedule,136.60% of BCBS custom fee schedule,11.3,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,10.27,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.21,38,,9.768,percent of total billed charges,38% of total billed charges,10.27,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.76,27.32,
insulin lispro 100 units/mL SubQ 10 mL Inj [FMC],2558831,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,38.25,22.95,,32.51,85,,26.008,Percent of total billed charges,85% of total billed charges,0.76,136.6,,2.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,1.728,fee schedule,136.60% of BCBS custom fee schedule,13.44,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,12.22,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.54,38,,11.632,percent of total billed charges,38% of total billed charges,12.22,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.76,32.51,
benzocaine Top 20% mucous membrane spray [FMC],2558906,CDM,250,RC,,,OUTPATIENT,59.7,UN,109.95,65.97,,93.46,85,,74.768,Percent of total billed charges,85% of total billed charges,54.98,50,,57.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,54.98,50,,1.632,percent of total billed charges,50% of total billed charges,35.13,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,35.13,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.78,38,,33.424,percent of total billed charges,38% of total billed charges,43.98,40,,1.408,percent of total billed charges,40% of total billed charges,35.13,93.46,
benzocaine Top 20% mucous membrane spray [FMC],2558906,CDM,250,RC,,,OUTPATIENT,59.7,UN,122.44,73.464,,104.07,85,,83.256,Percent of total billed charges,85% of total billed charges,61.22,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,61.22,50,,2.496,percent of total billed charges,50% of total billed charges,39.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,39.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.53,38,,37.224,percent of total billed charges,38% of total billed charges,48.98,40,,0.96,percent of total billed charges,40% of total billed charges,39.12,104.07,
benzocaine Top 20% mucous membrane spray [FMC],2558906,CDM,250,RC,,,OUTPATIENT,59.7,UN,128.34,77.004,,109.09,85,,87.272,Percent of total billed charges,85% of total billed charges,64.17,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.17,50,,1.808,percent of total billed charges,50% of total billed charges,41,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,41,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.77,38,,39.016,percent of total billed charges,38% of total billed charges,51.34,40,,2.856,percent of total billed charges,40% of total billed charges,41,109.09,
hydrocortisone Top 0.5% Crm [FMC],2558930,CDM,250,RC,,,OUTPATIENT,30,EA,10.99,6.594,,9.34,85,,7.472,Percent of total billed charges,85% of total billed charges,5.5,50,,8.856,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,3.248,percent of total billed charges,50% of total billed charges,3.51,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,3.344,percent of total billed charges,38% of total billed charges,4.4,40,,1.92,percent of total billed charges,40% of total billed charges,3.51,9.34,
hydrocortisone Top 0.5% Crm [FMC],2558930,CDM,250,RC,,,OUTPATIENT,30,EA,8.19,4.914,,6.96,85,,5.568,Percent of total billed charges,85% of total billed charges,4.1,50,,5.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.1,50,,2.696,percent of total billed charges,50% of total billed charges,2.62,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,2.62,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.11,38,,2.488,percent of total billed charges,38% of total billed charges,3.28,40,,1.92,percent of total billed charges,40% of total billed charges,2.62,6.96,
hydrALAZINE 10 mg Tab [FMC],2558963,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,9.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.616,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrALAZINE 10 mg Tab [FMC],2558963,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,9.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.616,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.856,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrALAZINE 10 mg Tab [FMC],2558963,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.856,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrALAZINE 10 mg Tab,2558963,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.296,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrocortisone Top 1% Crm [FMC],2558989,CDM,250,RC,,,OUTPATIENT,28.4,EA,13.15,7.89,,11.18,85,,8.944,Percent of total billed charges,85% of total billed charges,6.58,50,,1.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.58,50,,23.792,percent of total billed charges,50% of total billed charges,4.2,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.2,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5,38,,4,percent of total billed charges,38% of total billed charges,5.26,40,,0.96,percent of total billed charges,40% of total billed charges,4.2,11.18,
hydrocortisone Top 1% Crm [FMC],2558989,CDM,250,RC,,,OUTPATIENT,28.4,EA,16.92,10.152,,14.38,85,,11.504,Percent of total billed charges,85% of total billed charges,8.46,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.46,50,,24.768,percent of total billed charges,50% of total billed charges,5.41,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.41,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.43,38,,5.144,percent of total billed charges,38% of total billed charges,6.77,40,,0.96,percent of total billed charges,40% of total billed charges,5.41,14.38,
hydrocortisone Top 1% Crm [FMC],2558989,CDM,250,RC,,,OUTPATIENT,28.4,EA,9.39,5.634,,7.98,85,,6.384,Percent of total billed charges,85% of total billed charges,4.7,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.7,50,,29.72,percent of total billed charges,50% of total billed charges,3,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,3,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.57,38,,2.856,percent of total billed charges,38% of total billed charges,3.76,40,,1.744,percent of total billed charges,40% of total billed charges,3,7.98,
hydrocortisone Top 1% Crm [FMC],2558989,CDM,250,RC,,,OUTPATIENT,28.4,EA,16.92,10.152,,14.38,85,,11.504,Percent of total billed charges,85% of total billed charges,8.46,50,,24.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.46,50,,47.288,percent of total billed charges,50% of total billed charges,5.41,31.95,,1.376,percent of total billed charges,31.95% of total billed charges,5.41,31.95,,1.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.43,38,,5.144,percent of total billed charges,38% of total billed charges,6.77,40,,1.728,percent of total billed charges,40% of total billed charges,5.41,14.38,
hydroxychloroquine 200 mg Tab [FMC],2559011,CDM,250,RC,,,OUTPATIENT,1,EA,14.27,8.562,,12.13,85,,9.704,Percent of total billed charges,85% of total billed charges,7.14,50,,6.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.14,50,,43.208,percent of total billed charges,50% of total billed charges,4.56,31.95,,1.712,percent of total billed charges,31.95% of total billed charges,4.56,31.95,,1.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.42,38,,4.336,percent of total billed charges,38% of total billed charges,5.71,40,,2.144,percent of total billed charges,40% of total billed charges,4.56,12.13,
hydroxychloroquine 200 mg Tab [FMC],2559011,CDM,250,RC,,,OUTPATIENT,1,EA,9.87,5.922,,8.39,85,,6.712,Percent of total billed charges,85% of total billed charges,4.94,50,,19.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.94,50,,43.208,percent of total billed charges,50% of total billed charges,3.15,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,3.15,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.75,38,,3,percent of total billed charges,38% of total billed charges,3.95,40,,2.104,percent of total billed charges,40% of total billed charges,3.15,8.39,
hydroxychloroquine 200 mg Tab [FMC],2559011,CDM,250,RC,,,OUTPATIENT,1,EA,7.63,4.578,,6.49,85,,5.192,Percent of total billed charges,85% of total billed charges,3.82,50,,21.984,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.82,50,,43.208,percent of total billed charges,50% of total billed charges,2.44,31.95,,10.264,percent of total billed charges,31.95% of total billed charges,2.44,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.9,38,,2.32,percent of total billed charges,38% of total billed charges,3.05,40,,9.328,percent of total billed charges,40% of total billed charges,2.44,6.49,
hydroxychloroquine 200 mg Tab [FMC],2559011,CDM,250,RC,,,OUTPATIENT,1,EA,13.28,7.968,,11.29,85,,9.032,Percent of total billed charges,85% of total billed charges,6.64,50,,19.288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.64,50,,1.2,percent of total billed charges,50% of total billed charges,4.24,31.95,,7.24,percent of total billed charges,31.95% of total billed charges,4.24,31.95,,1.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.05,38,,4.04,percent of total billed charges,38% of total billed charges,5.31,40,,6.576,percent of total billed charges,40% of total billed charges,4.24,11.29,
hydroxychloroquine 200 mg Tab [FMC],2559011,CDM,250,RC,,,OUTPATIENT,1,EA,5.42,3.252,,4.61,85,,3.688,Percent of total billed charges,85% of total billed charges,2.71,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.71,50,,1.6,percent of total billed charges,50% of total billed charges,1.73,31.95,,7.784,percent of total billed charges,31.95% of total billed charges,1.73,31.95,,14.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.06,38,,1.648,percent of total billed charges,38% of total billed charges,2.17,40,,7.072,percent of total billed charges,40% of total billed charges,1.73,4.61,
hydroxychloroquine 200 mg Tab [FMC],2559011,CDM,250,RC,,,OUTPATIENT,1,EA,13.28,7.968,,11.29,85,,9.032,Percent of total billed charges,85% of total billed charges,6.64,50,,1.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.64,50,,1.6,percent of total billed charges,50% of total billed charges,4.24,31.95,,7.104,percent of total billed charges,31.95% of total billed charges,4.24,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.05,38,,4.04,percent of total billed charges,38% of total billed charges,5.31,40,,6.456,percent of total billed charges,40% of total billed charges,4.24,11.29,
hydrALAZINE 20 mg/mL Inj Sol [FMC],2559029,CDM,250,RC,J0360,HCPCS,OUTPATIENT,1,ML,55.85,33.51,,47.47,85,,37.976,Percent of total billed charges,85% of total billed charges,8.66,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.66,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,19.63,35.15,,6.72,percent of total billed charges,35.15% of total billed charges,10.54,31.95,,15.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.22,38,,16.976,percent of total billed charges,38% of total billed charges,17.84,31.95,,6.112,percent of total billed charges,31.95% of total billed charges,8.66,47.47,
hydrALAZINE 20 mg/mL Inj Sol [FMC],2559029,CDM,250,RC,J0360,HCPCS,OUTPATIENT,1,ML,172.48,103.488,,146.61,85,,117.288,Percent of total billed charges,85% of total billed charges,8.66,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.66,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,60.63,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,11.18,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,65.54,38,,52.432,percent of total billed charges,38% of total billed charges,55.11,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,8.66,146.61,
hydrALAZINE 20 mg/mL Inj Sol [FMC],2559029,CDM,250,RC,J0360,HCPCS,OUTPATIENT,1,ML,46.8,28.08,,39.78,85,,31.824,Percent of total billed charges,85% of total billed charges,8.66,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.66,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,16.45,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,14.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.78,38,,14.224,percent of total billed charges,38% of total billed charges,14.95,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,8.66,39.78,
hydrALAZINE 20 mg/mL Inj Sol [FMC],2559029,CDM,250,RC,J0360,HCPCS,OUTPATIENT,1,ML,36.56,21.936,,31.08,85,,24.864,Percent of total billed charges,85% of total billed charges,8.66,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.66,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,12.85,35.15,,2.624,percent of total billed charges,35.15% of total billed charges,2.88,31.95,,2.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.89,38,,11.112,percent of total billed charges,38% of total billed charges,11.68,31.95,,3.288,percent of total billed charges,31.95% of total billed charges,2.88,31.08,
hydrALAZINE 20 mg/mL Inj Sol [FMC],2559029,CDM,250,RC,J0360,HCPCS,OUTPATIENT,1,ML,58.5,35.1,,49.73,85,,39.784,Percent of total billed charges,85% of total billed charges,8.66,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.66,136.6,,5.888,fee schedule,136.60% of BCBS custom fee schedule,20.56,35.15,,2.92,percent of total billed charges,35.15% of total billed charges,1.29,31.95,,2.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.23,38,,17.784,percent of total billed charges,38% of total billed charges,18.69,31.95,,3.656,percent of total billed charges,31.95% of total billed charges,1.29,49.73,
hydrOXYzine hydrochloride 25 mg Tab [FMC],2559037,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.528,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.776,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.472,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrOXYzine hydrochloride 25 mg Tab [FMC],2559037,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.496,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.92,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.656,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrOXYzine hydrochloride 25 mg Tab [FMC],2559037,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.496,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrocortisone 25mg Suppos {FMC],2559045,CDM,250,RC,,,OUTPATIENT,1,EA,23.21,13.926,,19.73,85,,15.784,Percent of total billed charges,85% of total billed charges,11.61,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.61,50,,7.44,percent of total billed charges,50% of total billed charges,7.42,31.95,,8.288,percent of total billed charges,31.95% of total billed charges,7.42,31.95,,8.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.82,38,,7.056,percent of total billed charges,38% of total billed charges,9.28,40,,10.376,percent of total billed charges,40% of total billed charges,7.42,19.73,
hydrocortisone 25mg Suppos {FMC],2559045,CDM,250,RC,,,OUTPATIENT,1,EA,73.6,44.16,,62.56,85,,50.048,Percent of total billed charges,85% of total billed charges,36.8,50,,101.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36.8,50,,8.304,percent of total billed charges,50% of total billed charges,23.52,31.95,,13.296,percent of total billed charges,31.95% of total billed charges,23.52,31.95,,13.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.97,38,,22.376,percent of total billed charges,38% of total billed charges,29.44,40,,16.648,percent of total billed charges,40% of total billed charges,23.52,62.56,
hydrocortisone 25mg Suppos {FMC],2559045,CDM,250,RC,,,OUTPATIENT,1,EA,40.15,24.09,,34.13,85,,27.304,Percent of total billed charges,85% of total billed charges,20.08,50,,71.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.08,50,,6.52,percent of total billed charges,50% of total billed charges,12.83,31.95,,8.12,percent of total billed charges,31.95% of total billed charges,12.83,31.95,,8.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.26,38,,12.208,percent of total billed charges,38% of total billed charges,16.06,40,,10.168,percent of total billed charges,40% of total billed charges,12.83,34.13,
hydrocortisone 25mg Suppos {FMC],2559045,CDM,250,RC,,,OUTPATIENT,1,EA,73.67,44.202,,62.62,85,,50.096,Percent of total billed charges,85% of total billed charges,36.84,50,,8.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36.84,50,,1.36,percent of total billed charges,50% of total billed charges,23.54,31.95,,12.704,percent of total billed charges,31.95% of total billed charges,23.54,31.95,,12.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.99,38,,22.392,percent of total billed charges,38% of total billed charges,29.47,40,,15.904,percent of total billed charges,40% of total billed charges,23.54,62.62,
hydrocortisone 25mg Suppos {FMC],2559045,CDM,250,RC,,,OUTPATIENT,1,EA,73.6,44.16,,62.56,85,,50.048,Percent of total billed charges,85% of total billed charges,36.8,50,,8.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36.8,50,,1.776,percent of total billed charges,50% of total billed charges,23.52,31.95,,0.944,percent of total billed charges,31.95% of total billed charges,23.52,31.95,,0.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.97,38,,22.376,percent of total billed charges,38% of total billed charges,29.44,40,,1.184,percent of total billed charges,40% of total billed charges,23.52,62.56,
hydrALAZINE 25 mg Tab [FMC],2559052,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.384,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.24,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrALAZINE 25 mg Tab [FMC],2559052,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.624,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.288,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrALAZINE 25 mg Tab [FMC],2559052,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.224,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.152,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.944,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrALAZINE 25 mg Tab [FMC],2559052,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,16.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.064,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrALAZINE 25 mg Tab [FMC],2559052,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.48,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.984,percent of total billed charges,40% of total billed charges,0.96,2.55,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,1.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,1.2,percent of total billed charges,50% of total billed charges,4.92,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,3.43,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.43,11.9,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,1.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,1.2,percent of total billed charges,50% of total billed charges,4.92,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,4.15,31.95,,22.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4.15,11.9,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,1.608,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,1.2,percent of total billed charges,50% of total billed charges,4.92,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4.47,11.9,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,1.2,percent of total billed charges,50% of total billed charges,4.92,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,5.43,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4.47,11.9,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,14.04,8.424,,11.93,85,,9.544,Percent of total billed charges,85% of total billed charges,7.02,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.02,50,,1.2,percent of total billed charges,50% of total billed charges,4.94,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,0.64,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.34,38,,4.272,percent of total billed charges,38% of total billed charges,4.49,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.64,11.93,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,20.17,12.102,,17.14,85,,13.712,Percent of total billed charges,85% of total billed charges,10.09,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.09,50,,1.2,percent of total billed charges,50% of total billed charges,7.09,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,0.64,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.66,38,,6.128,percent of total billed charges,38% of total billed charges,6.44,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.64,17.14,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,1.568,percent of total billed charges,50% of total billed charges,4.92,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,0.64,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.64,11.9,
HYDROmorphone 2 mg/mL Inj Soln [FMC],2559060,CDM,250,RC,J1171,HCPCS,OUTPATIENT,1,ML,16.19,9.714,,13.76,85,,11.008,Percent of total billed charges,85% of total billed charges,8.1,50,,17.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.1,50,,1.912,percent of total billed charges,50% of total billed charges,5.69,35.15,,5.472,percent of total billed charges,35.15% of total billed charges,0.64,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.15,38,,4.92,percent of total billed charges,38% of total billed charges,5.17,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,0.64,13.76,
hydroxyurea 500 mg Cap [FMC],2559086,CDM,250,RC,S0176,HCPCS,OUTPATIENT,1,EA,3.59,2.154,,3.05,85,,2.44,Percent of total billed charges,85% of total billed charges,1.5,136.6,,16.36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.5,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1.26,35.15,,3.48,percent of total billed charges,35.15% of total billed charges,6.71,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.36,38,,1.088,percent of total billed charges,38% of total billed charges,1.15,31.95,,3.168,percent of total billed charges,31.95% of total billed charges,1.15,6.71,
hydroxyurea 500 mg Cap [FMC],2559086,CDM,250,RC,S0176,HCPCS,OUTPATIENT,1,EA,4.15,2.49,,3.53,85,,2.824,Percent of total billed charges,85% of total billed charges,1.5,136.6,,275.032,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.5,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1.46,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,7.07,31.95,,42.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.58,38,,1.264,percent of total billed charges,38% of total billed charges,1.33,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.33,7.07,
hydroxyurea 500 mg Cap [FMC],2559086,CDM,250,RC,S0176,HCPCS,OUTPATIENT,1,EA,3.76,2.256,,3.2,85,,2.56,Percent of total billed charges,85% of total billed charges,1.5,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.5,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1.32,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,7.67,31.95,,32.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.43,38,,1.144,percent of total billed charges,38% of total billed charges,1.2,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.2,7.67,
hydrOXYzine hydrochloride 25 mg/mL IM Sol [FMC],2559094,CDM,250,RC,J3410,HCPCS,OUTPATIENT,1,ML,41.44,24.864,,35.22,85,,28.176,Percent of total billed charges,85% of total billed charges,19.77,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.77,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,14.57,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,9.27,31.95,,35.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.75,38,,12.6,percent of total billed charges,38% of total billed charges,13.24,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,9.27,35.22,
hydrOXYzine hydrochloride 10 mg Tab [FMC],2559128,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,36.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.064,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrOXYzine hydrochloride 10 mg Tab [FMC],2559128,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,11.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.856,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,44.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.232,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrOXYzine hydrochloride 10 mg Tab [FMC],2559128,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.248,percent of total billed charges,50% of total billed charges,0.96,31.95,,109.032,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,109.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,136.496,percent of total billed charges,40% of total billed charges,0.96,2.55,
hyoscyamine 0.125 mg/mL Oral Sol [FMC],2559169,CDM,250,RC,,,OUTPATIENT,15,ML,129.32,77.592,,109.92,85,,87.936,Percent of total billed charges,85% of total billed charges,64.66,50,,5.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.66,50,,1.2,percent of total billed charges,50% of total billed charges,41.32,31.95,,25.672,percent of total billed charges,31.95% of total billed charges,41.32,31.95,,25.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.14,38,,39.312,percent of total billed charges,38% of total billed charges,51.73,40,,32.136,percent of total billed charges,40% of total billed charges,41.32,109.92,
hyoscyamine 0.125 mg/mL Oral Sol [FMC],2559169,CDM,250,RC,,,OUTPATIENT,15,ML,129.97,77.982,,110.47,85,,88.376,Percent of total billed charges,85% of total billed charges,64.99,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.99,50,,1.2,percent of total billed charges,50% of total billed charges,41.53,31.95,,109.096,percent of total billed charges,31.95% of total billed charges,41.53,31.95,,109.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.39,38,,39.512,percent of total billed charges,38% of total billed charges,51.99,40,,136.584,percent of total billed charges,40% of total billed charges,41.53,110.47,
hyoscyamine 0.375 mg ER Tab [FMC],2559185,CDM,250,RC,,,OUTPATIENT,1,EA,3.21,1.926,,2.73,85,,2.184,Percent of total billed charges,85% of total billed charges,1.61,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.61,50,,1.2,percent of total billed charges,50% of total billed charges,1.03,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,1.03,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.22,38,,0.976,percent of total billed charges,38% of total billed charges,1.28,40,,4.496,percent of total billed charges,40% of total billed charges,1.03,2.73,
hyoscyamine 0.375 mg ER Tab [FMC],2559185,CDM,250,RC,,,OUTPATIENT,1,EA,3.25,1.95,,2.76,85,,2.208,Percent of total billed charges,85% of total billed charges,1.63,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.63,50,,1.384,percent of total billed charges,50% of total billed charges,1.04,31.95,,7.272,percent of total billed charges,31.95% of total billed charges,1.04,31.95,,7.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.24,38,,0.992,percent of total billed charges,38% of total billed charges,1.3,40,,9.104,percent of total billed charges,40% of total billed charges,1.04,2.76,
ibuprofen 400 mg Tab [FMC],2559235,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 400 mg Tab [FMC],2559235,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.424,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.304,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 400 mg Tab [FMC],2559235,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.984,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 400 mg Tab [FMC],2559235,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,25.96,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,25.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,32.496,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 600 mg Tab [FMC],2559243,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 600 mg Tab [FMC],2559243,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.896,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.368,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 600 mg Tab [FMC],2559243,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,9.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 600 mg Tab [FMC],2559243,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 800 mg Tab [FMC],2559250,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,6.448,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
ibuprofen 800 mg Tab [FMC],2559250,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,15.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
ibuprofen 800 mg Tab [FMC],2559250,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,11.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.312,percent of total billed charges,40% of total billed charges,1.28,3.4,
ibuprofen 800 mg Tab [FMC],2559250,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,15.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
ibuprofen 800 mg Tab [FMC],2559250,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.896,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.944,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,4.944,percent of total billed charges,40% of total billed charges,1.28,3.4,
ascorbic acid-carbonyl iron 250 mg-100 mg Tab [FMC],2559284,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.056,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
ascorbic acid-carbonyl iron 250 mg-100 mg Tab [FMC],2559284,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.584,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.28,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
imipramine 25 mg Tab [FMC],2559359,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.656,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.944,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.944,percent of total billed charges,40% of total billed charges,0.96,2.55,
imipramine 25 mg Tab [FMC],2559359,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.816,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,10.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,13.544,percent of total billed charges,40% of total billed charges,0.96,2.55,
imipramine 25 mg Tab [FMC],2559359,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.072,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.864,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,10.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,13.6,percent of total billed charges,40% of total billed charges,0.96,2.55,
SUMAtriptan 100 mg Tab [FMC],2559367,CDM,250,RC,,,OUTPATIENT,1,EA,81.71,49.026,,69.45,85,,55.56,Percent of total billed charges,85% of total billed charges,40.86,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.86,50,,1.2,percent of total billed charges,50% of total billed charges,26.11,31.95,,10.816,percent of total billed charges,31.95% of total billed charges,26.11,31.95,,10.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.05,38,,24.84,percent of total billed charges,38% of total billed charges,32.68,40,,13.544,percent of total billed charges,40% of total billed charges,26.11,69.45,
SUMAtriptan 100mg Tab {FMC],2559367,CDM,250,RC,,,OUTPATIENT,1,EA,81.71,49.026,,69.45,85,,55.56,Percent of total billed charges,85% of total billed charges,40.86,50,,5.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.86,50,,1.2,percent of total billed charges,50% of total billed charges,26.11,31.95,,10.816,percent of total billed charges,31.95% of total billed charges,26.11,31.95,,10.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.05,38,,24.84,percent of total billed charges,38% of total billed charges,32.68,40,,13.544,percent of total billed charges,40% of total billed charges,26.11,69.45,
SUMAtriptan 100 mg Tab [FMC],2559367,CDM,250,RC,,,OUTPATIENT,1,EA,81.71,49.026,,69.45,85,,55.56,Percent of total billed charges,85% of total billed charges,40.86,50,,3.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.86,50,,7.52,percent of total billed charges,50% of total billed charges,26.11,31.95,,3.456,percent of total billed charges,31.95% of total billed charges,26.11,31.95,,3.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.05,38,,24.84,percent of total billed charges,38% of total billed charges,32.68,40,,4.328,percent of total billed charges,40% of total billed charges,26.11,69.45,
SUMAtriptan 100 mg Tab [FMC],2559367,CDM,250,RC,,,OUTPATIENT,1,EA,81.72,49.032,,69.46,85,,55.568,Percent of total billed charges,85% of total billed charges,40.86,50,,5.904,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.86,50,,7.176,percent of total billed charges,50% of total billed charges,26.11,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,26.11,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.05,38,,24.84,percent of total billed charges,38% of total billed charges,32.69,40,,0.96,percent of total billed charges,40% of total billed charges,26.11,69.46,
SUMAtriptan 100 mg Tab [FMC],2559367,CDM,250,RC,,,OUTPATIENT,1,EA,81.71,49.026,,69.45,85,,55.56,Percent of total billed charges,85% of total billed charges,40.86,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.86,50,,7.168,percent of total billed charges,50% of total billed charges,26.11,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,26.11,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.05,38,,24.84,percent of total billed charges,38% of total billed charges,32.68,40,,0.96,percent of total billed charges,40% of total billed charges,26.11,69.45,
SUMAtriptan 6 mg/0.5 mL SubQ Sol [FMC],2559391,CDM,250,RC,J3030,HCPCS,OUTPATIENT,0.5,ML,93.6,56.16,,79.56,85,,63.648,Percent of total billed charges,85% of total billed charges,110.3,136.6,,1.712,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,110.3,136.6,,7.144,fee schedule,136.60% of BCBS custom fee schedule,32.9,35.15,,2.392,percent of total billed charges,35.15% of total billed charges,0.99,31.95,,2.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.57,38,,28.456,percent of total billed charges,38% of total billed charges,29.91,31.95,,2.992,percent of total billed charges,31.95% of total billed charges,0.99,110.3,
SUMAtriptan 6 mg/0.5 mL Sol [FMC],2559391,CDM,250,RC,J3030,HCPCS,OUTPATIENT,0.5,ML,276.25,165.75,,234.81,85,,187.848,Percent of total billed charges,85% of total billed charges,110.3,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,110.3,136.6,,2.752,fee schedule,136.60% of BCBS custom fee schedule,97.1,35.15,,1.4,percent of total billed charges,35.15% of total billed charges,10.86,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.98,38,,83.984,percent of total billed charges,38% of total billed charges,88.26,31.95,,1.752,percent of total billed charges,31.95% of total billed charges,10.86,234.81,
SUMAtriptan 6 mg/0.5 mL SubQ Sol [FMC],2559391,CDM,250,RC,J3030,HCPCS,OUTPATIENT,0.5,ML,572.82,343.692,,486.9,85,,389.52,Percent of total billed charges,85% of total billed charges,110.3,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,110.3,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,201.35,35.15,,1.912,percent of total billed charges,35.15% of total billed charges,12.42,31.95,,1.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,217.67,38,,174.136,percent of total billed charges,38% of total billed charges,183.02,31.95,,2.392,percent of total billed charges,31.95% of total billed charges,12.42,486.9,
SUMAtriptan 6 mg/0.5 mL Sol [FMC],2559391,CDM,250,RC,J3030,HCPCS,OUTPATIENT,0.5,ML,276.25,165.75,,234.81,85,,187.848,Percent of total billed charges,85% of total billed charges,110.3,136.6,,10.568,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,110.3,136.6,,4.344,fee schedule,136.60% of BCBS custom fee schedule,97.1,35.15,,1.424,percent of total billed charges,35.15% of total billed charges,14.38,31.95,,1.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.98,38,,83.984,percent of total billed charges,38% of total billed charges,88.26,31.95,,1.784,percent of total billed charges,31.95% of total billed charges,14.38,234.81,
propranolol 1 mg/mL IV Sol [FMC],2559433,CDM,250,RC,J1800,HCPCS,OUTPATIENT,1,ML,32.5,19.5,,27.63,85,,22.104,Percent of total billed charges,85% of total billed charges,12.46,136.6,,10.576,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,12.46,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,11.42,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,1.6,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.35,38,,9.88,percent of total billed charges,38% of total billed charges,10.38,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.6,27.63,
propranolol 1 mg/mL IV Sol [FMC],2559433,CDM,250,RC,J1800,HCPCS,OUTPATIENT,1,ML,39.27,23.562,,33.38,85,,26.704,Percent of total billed charges,85% of total billed charges,12.46,136.6,,10.144,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,12.46,136.6,,3.824,fee schedule,136.60% of BCBS custom fee schedule,13.8,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,1.6,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.92,38,,11.936,percent of total billed charges,38% of total billed charges,12.55,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.6,33.38,
digoxin 125 mcg (0.125 mg) Tab [FMC],2559441,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
digoxin 125 mcg (0.125 mg) Tab [FMC],2559441,CDM,250,RC,,,OUTPATIENT,1,EA,8.32,4.992,,7.07,85,,5.656,Percent of total billed charges,85% of total billed charges,4.16,50,,1.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.16,50,,1.28,percent of total billed charges,50% of total billed charges,2.66,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.66,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.16,38,,2.528,percent of total billed charges,38% of total billed charges,3.33,40,,0.96,percent of total billed charges,40% of total billed charges,2.66,7.07,
digoxin 125 mcg (0.125 mg) Tab [FMC],2559441,CDM,250,RC,,,OUTPATIENT,1,EA,5.48,3.288,,4.66,85,,3.728,Percent of total billed charges,85% of total billed charges,2.74,50,,2.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.74,50,,3.616,percent of total billed charges,50% of total billed charges,1.75,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.08,38,,1.664,percent of total billed charges,38% of total billed charges,2.19,40,,1.256,percent of total billed charges,40% of total billed charges,1.75,4.66,
digoxin 125 mcg (0.125 mg) Tab [FMC],2559441,CDM,250,RC,,,OUTPATIENT,1,EA,8.32,4.992,,7.07,85,,5.656,Percent of total billed charges,85% of total billed charges,4.16,50,,1.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.16,50,,2.432,percent of total billed charges,50% of total billed charges,2.66,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.66,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.16,38,,2.528,percent of total billed charges,38% of total billed charges,3.33,40,,0.96,percent of total billed charges,40% of total billed charges,2.66,7.07,
digoxin 125 mcg (0.125 mg) Tab [FMC],2559441,CDM,250,RC,,,OUTPATIENT,1,EA,7.48,4.488,,6.36,85,,5.088,Percent of total billed charges,85% of total billed charges,3.74,50,,2.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.74,50,,6.232,percent of total billed charges,50% of total billed charges,2.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.84,38,,2.272,percent of total billed charges,38% of total billed charges,2.99,40,,0.96,percent of total billed charges,40% of total billed charges,2.39,6.36,
indomethacin 25 mg Cap [FMC],2559458,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.176,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.472,percent of total billed charges,40% of total billed charges,0.96,2.55,
indomethacin 25 mg Cap [FMC],2559458,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.296,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
isosorbide dinitrate 20 mg Tab [FMC],2559573,CDM,250,RC,,,OUTPATIENT,1,EA,4.39,2.634,,3.73,85,,2.984,Percent of total billed charges,85% of total billed charges,2.2,50,,2.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.2,50,,6.216,percent of total billed charges,50% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.67,38,,1.336,percent of total billed charges,38% of total billed charges,1.76,40,,0.96,percent of total billed charges,40% of total billed charges,1.4,3.73,
isosorbide dinitrate 20 mg Tab [FMC],2559573,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.296,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.992,percent of total billed charges,40% of total billed charges,0.96,2.55,
isopropyl alcohol Top 70% Liq [FMC],2559649,CDM,250,RC,,,OUTPATIENT,473,EA,8.93,5.358,,7.59,85,,6.072,Percent of total billed charges,85% of total billed charges,4.47,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.47,50,,12.448,percent of total billed charges,50% of total billed charges,2.85,31.95,,1.504,percent of total billed charges,31.95% of total billed charges,2.85,31.95,,1.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.39,38,,2.712,percent of total billed charges,38% of total billed charges,3.57,40,,1.88,percent of total billed charges,40% of total billed charges,2.85,7.59,
isopropyl alcohol Top 70% Liq [FMC],2559649,CDM,250,RC,,,OUTPATIENT,473,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,7.28,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
isopropyl alcohol Top 70% Liq [FMC],2559649,CDM,250,RC,,,OUTPATIENT,473,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,1.2,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
isopropyl alcohol topical 70 % Liq,2559649,CDM,250,RC,,,OUTPATIENT,473,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,1.2,percent of total billed charges,50% of total billed charges,1.92,31.95,,8.296,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,8.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,10.384,percent of total billed charges,40% of total billed charges,1.92,5.1,
isopropyl alcohol topical 70 % Liq [FMC],2559649,CDM,250,RC,,,OUTPATIENT,473,EA,8.92,5.352,,7.58,85,,6.064,Percent of total billed charges,85% of total billed charges,4.46,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.46,50,,1.2,percent of total billed charges,50% of total billed charges,2.85,31.95,,14.456,percent of total billed charges,31.95% of total billed charges,2.85,31.95,,14.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.39,38,,2.712,percent of total billed charges,38% of total billed charges,3.57,40,,18.096,percent of total billed charges,40% of total billed charges,2.85,7.58,
isopropyl alcohol topical 70 % Liq [FMC},2559649,CDM,250,RC,,,OUTPATIENT,473,EA,8.92,5.352,,7.58,85,,6.064,Percent of total billed charges,85% of total billed charges,4.46,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.46,50,,1.216,percent of total billed charges,50% of total billed charges,2.85,31.95,,8.712,percent of total billed charges,31.95% of total billed charges,2.85,31.95,,8.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.39,38,,2.712,percent of total billed charges,38% of total billed charges,3.57,40,,10.912,percent of total billed charges,40% of total billed charges,2.85,7.58,
isosorbide dinitrate 10 mg Tab [FMC],2559656,CDM,250,RC,,,OUTPATIENT,1,EA,4.06,2.436,,3.45,85,,2.76,Percent of total billed charges,85% of total billed charges,2.03,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.03,50,,2.464,percent of total billed charges,50% of total billed charges,1.3,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,1.3,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.54,38,,1.232,percent of total billed charges,38% of total billed charges,1.62,40,,6.24,percent of total billed charges,40% of total billed charges,1.3,3.45,
isosorbide dinitrate 10 mg Tab [FMC],2559656,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,17.864,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,17.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,22.36,percent of total billed charges,40% of total billed charges,0.96,2.55,
isosorbide dinitrate 10 mg Tab [FMC],2559656,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,343.984,percent of total billed charges,50% of total billed charges,0.96,31.95,,33.248,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,21.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,30.224,percent of total billed charges,40% of total billed charges,0.96,2.55,
isosorbide mononitrate 30 mg ER  UD [FMC],2559672,CDM,250,RC,,,OUTPATIENT,1,EA,5.45,3.27,,4.63,85,,3.704,Percent of total billed charges,85% of total billed charges,2.73,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.73,50,,11.832,percent of total billed charges,50% of total billed charges,1.74,31.95,,33.248,percent of total billed charges,31.95% of total billed charges,1.74,31.95,,31.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.07,38,,1.656,percent of total billed charges,38% of total billed charges,2.18,40,,30.224,percent of total billed charges,40% of total billed charges,1.74,4.63,
isosorbide mononitrate 30 mg ER UD [FMC],2559672,CDM,250,RC,,,OUTPATIENT,1,EA,5.39,3.234,,4.58,85,,3.664,Percent of total billed charges,85% of total billed charges,2.7,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.7,50,,15.784,percent of total billed charges,50% of total billed charges,1.72,31.95,,72.384,percent of total billed charges,31.95% of total billed charges,1.72,31.95,,111.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.05,38,,1.64,percent of total billed charges,38% of total billed charges,2.16,40,,65.792,percent of total billed charges,40% of total billed charges,1.72,4.58,
isosorbide mononitrate 60 mg ER Tab [FMC],2559706,CDM,250,RC,,,OUTPATIENT,1,EA,6.69,4.014,,5.69,85,,4.552,Percent of total billed charges,85% of total billed charges,3.35,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.35,50,,1.2,percent of total billed charges,50% of total billed charges,2.14,31.95,,3.64,percent of total billed charges,31.95% of total billed charges,2.14,31.95,,3.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.54,38,,2.032,percent of total billed charges,38% of total billed charges,2.68,40,,4.56,percent of total billed charges,40% of total billed charges,2.14,5.69,
isosorbide mononitrate 60 mg ER Tab [FMC],2559706,CDM,250,RC,,,OUTPATIENT,1,EA,6.58,3.948,,5.59,85,,4.472,Percent of total billed charges,85% of total billed charges,3.29,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.29,50,,1.528,percent of total billed charges,50% of total billed charges,2.1,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,2.1,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.5,38,,2,percent of total billed charges,38% of total billed charges,2.63,40,,9.2,percent of total billed charges,40% of total billed charges,2.1,5.59,
triamcinolone acetonide 40 mg/mL Inj Susp [FMC],2559847,CDM,250,RC,J3301,HCPCS,OUTPATIENT,1,ML,36.5,21.9,,31.03,85,,24.824,Percent of total billed charges,85% of total billed charges,1.75,136.6,,8.896,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.75,136.6,,1.736,fee schedule,136.60% of BCBS custom fee schedule,12.83,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,1.6,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.87,38,,11.096,percent of total billed charges,38% of total billed charges,11.66,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.6,31.03,
triamcinolone acetonide 40 mg/mL Inj Susp [FMC],2559847,CDM,250,RC,J3301,HCPCS,OUTPATIENT,1,ML,25.74,15.444,,21.88,85,,17.504,Percent of total billed charges,85% of total billed charges,1.75,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.75,136.6,,1.608,fee schedule,136.60% of BCBS custom fee schedule,9.05,35.15,,14.808,percent of total billed charges,35.15% of total billed charges,1.9,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.78,38,,7.824,percent of total billed charges,38% of total billed charges,8.22,31.95,,13.456,percent of total billed charges,31.95% of total billed charges,1.75,21.88,
triamcinolone acetonide 40 mg/mL Inj Susp [FMC],2559847,CDM,250,RC,J3301,HCPCS,OUTPATIENT,1,ML,27.67,16.602,,23.52,85,,18.816,Percent of total billed charges,85% of total billed charges,1.75,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,9.73,35.15,,5.448,percent of total billed charges,35.15% of total billed charges,18.72,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.51,38,,8.408,percent of total billed charges,38% of total billed charges,8.84,31.95,,4.952,percent of total billed charges,31.95% of total billed charges,1.75,23.52,
triamcinolone acetonide 40 mg/mL Inj Susp [FMC],2559847,CDM,250,RC,J3301,HCPCS,OUTPATIENT,1,ML,25.25,15.15,,21.46,85,,17.168,Percent of total billed charges,85% of total billed charges,1.75,136.6,,8.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.88,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,1.92,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.6,38,,7.68,percent of total billed charges,38% of total billed charges,8.07,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.75,21.46,
triamcinolone acetonide 40 mg/mL Inj Susp [FMC],2559847,CDM,250,RC,J3301,HCPCS,OUTPATIENT,1,ML,23.91,14.346,,20.32,85,,16.256,Percent of total billed charges,85% of total billed charges,1.75,136.6,,8.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.4,35.15,,7.4,percent of total billed charges,35.15% of total billed charges,19.49,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.09,38,,7.272,percent of total billed charges,38% of total billed charges,7.64,31.95,,6.728,percent of total billed charges,31.95% of total billed charges,1.75,20.32,
levETIRAcetam 500 mg Tab [FMC],2559870,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.912,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.384,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.504,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,39.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.096,percent of total billed charges,40% of total billed charges,0.96,2.55,
levETIRAcetam 500 mg Tab [FMC],2559870,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.384,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.696,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,26.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.272,percent of total billed charges,40% of total billed charges,0.96,2.55,
levETIRAcetam 500 mg Tab [FMC],2559870,CDM,250,RC,,,OUTPATIENT,1,EA,10.28,6.168,,8.74,85,,6.992,Percent of total billed charges,85% of total billed charges,5.14,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.14,50,,1.288,percent of total billed charges,50% of total billed charges,3.28,31.95,,8.536,percent of total billed charges,31.95% of total billed charges,3.28,31.95,,8.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.91,38,,3.128,percent of total billed charges,38% of total billed charges,4.11,40,,10.688,percent of total billed charges,40% of total billed charges,3.28,8.74,
levETIRAcetam 500 mg Tab [FMC],2559870,CDM,250,RC,,,OUTPATIENT,1,EA,11.42,6.852,,9.71,85,,7.768,Percent of total billed charges,85% of total billed charges,5.71,50,,1.488,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.71,50,,1.384,percent of total billed charges,50% of total billed charges,3.65,31.95,,7.776,percent of total billed charges,31.95% of total billed charges,3.65,31.95,,7.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.34,38,,3.472,percent of total billed charges,38% of total billed charges,4.57,40,,9.736,percent of total billed charges,40% of total billed charges,3.65,9.71,
levETIRAcetam 500 mg Tab [FMC],2559870,CDM,250,RC,,,OUTPATIENT,1,EA,10.85,6.51,,9.22,85,,7.376,Percent of total billed charges,85% of total billed charges,5.43,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.43,50,,1.744,percent of total billed charges,50% of total billed charges,3.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.12,38,,3.296,percent of total billed charges,38% of total billed charges,4.34,40,,0.96,percent of total billed charges,40% of total billed charges,3.47,9.22,
levETIRAcetam 500 mg Tab [FMC],2559870,CDM,250,RC,,,OUTPATIENT,1,EA,11.42,6.852,,9.71,85,,7.768,Percent of total billed charges,85% of total billed charges,5.71,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.71,50,,1.2,percent of total billed charges,50% of total billed charges,3.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.34,38,,3.472,percent of total billed charges,38% of total billed charges,4.57,40,,0.96,percent of total billed charges,40% of total billed charges,3.65,9.71,
levETIRAcetam 500 mg Tab [FMC],2559870,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.744,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
ketamine 100 mg/mL Inj Sol [FMC],2559888,CDM,250,RC,,,OUTPATIENT,5,ML,32.42,19.452,,27.56,85,,22.048,Percent of total billed charges,85% of total billed charges,16.21,50,,1.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.21,50,,16.768,percent of total billed charges,50% of total billed charges,10.36,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,10.36,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.32,38,,9.856,percent of total billed charges,38% of total billed charges,12.97,40,,0.96,percent of total billed charges,40% of total billed charges,10.36,27.56,
ketamine 100 mg/mL Inj Sol [FMC],2559888,CDM,250,RC,,,OUTPATIENT,5,ML,52.02,31.212,,44.22,85,,35.376,Percent of total billed charges,85% of total billed charges,26.01,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.01,50,,71.824,percent of total billed charges,50% of total billed charges,16.62,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,16.62,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.77,38,,15.816,percent of total billed charges,38% of total billed charges,20.81,40,,0.96,percent of total billed charges,40% of total billed charges,16.62,44.22,
ketamine 100 mg/mL Inj Sol [FMC],2559888,CDM,250,RC,,,OUTPATIENT,5,ML,31.78,19.068,,27.01,85,,21.608,Percent of total billed charges,85% of total billed charges,15.89,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.89,50,,74.04,percent of total billed charges,50% of total billed charges,10.15,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,10.15,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.08,38,,9.664,percent of total billed charges,38% of total billed charges,12.71,40,,1.28,percent of total billed charges,40% of total billed charges,10.15,27.01,
ketamine 100 mg/mL Inj Sol [FMC],2559888,CDM,250,RC,,,OUTPATIENT,5,ML,49.69,29.814,,42.24,85,,33.792,Percent of total billed charges,85% of total billed charges,24.85,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.85,50,,68.304,percent of total billed charges,50% of total billed charges,15.88,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,15.88,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.88,38,,15.104,percent of total billed charges,38% of total billed charges,19.88,40,,1.28,percent of total billed charges,40% of total billed charges,15.88,42.24,
ketorolac 10 mg Tab [FMC],2559896,CDM,250,RC,,,OUTPATIENT,1,EA,3.69,2.214,,3.14,85,,2.512,Percent of total billed charges,85% of total billed charges,1.85,50,,2.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.85,50,,74.04,percent of total billed charges,50% of total billed charges,1.18,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.18,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.4,38,,1.12,percent of total billed charges,38% of total billed charges,1.48,40,,1.28,percent of total billed charges,40% of total billed charges,1.18,3.14,
ketorolac 10 mg Tab [FMC],2559896,CDM,250,RC,,,OUTPATIENT,1,EA,7.01,4.206,,5.96,85,,4.768,Percent of total billed charges,85% of total billed charges,3.51,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.51,50,,25.824,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,2.128,percent of total billed charges,38% of total billed charges,2.8,40,,1.28,percent of total billed charges,40% of total billed charges,2.24,5.96,
ketoconazole 200 mg Tab [FMC],2559912,CDM,250,RC,,,OUTPATIENT,1,EA,10.27,6.162,,8.73,85,,6.984,Percent of total billed charges,85% of total billed charges,5.14,50,,1.448,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.14,50,,57.2,percent of total billed charges,50% of total billed charges,3.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,3.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.9,38,,3.12,percent of total billed charges,38% of total billed charges,4.11,40,,1.28,percent of total billed charges,40% of total billed charges,3.28,8.73,
ketoconazole 200 mg Tab [FMC],2559912,CDM,250,RC,,,OUTPATIENT,1,EA,12.32,7.392,,10.47,85,,8.376,Percent of total billed charges,85% of total billed charges,6.16,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.16,50,,5.552,percent of total billed charges,50% of total billed charges,3.94,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,3.94,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.68,38,,3.744,percent of total billed charges,38% of total billed charges,4.93,40,,1.28,percent of total billed charges,40% of total billed charges,3.94,10.47,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,3.048,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,20.13,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.92,20.13,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,19.5,11.7,,16.58,85,,13.264,Percent of total billed charges,85% of total billed charges,0.92,136.6,,7.352,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,6.85,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,2.24,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.41,38,,5.928,percent of total billed charges,38% of total billed charges,6.23,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.92,16.58,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,4.76,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,2.56,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.92,10.2,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,3.032,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,27.8,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.92,27.8,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,2.88,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.92,10.2,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,2.88,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,0.92,10.2,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,2.88,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,0.92,10.2,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,2.88,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,0.92,10.2,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,14.624,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.76,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,28.76,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,0.92,28.76,
ketorolac 30 mg/mL Inj Sol [FMC],2559920,CDM,250,RC,J1885,HCPCS,OUTPATIENT,1,ML,19.46,11.676,,16.54,85,,13.232,Percent of total billed charges,85% of total billed charges,0.92,136.6,,32.664,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,6.84,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,4.15,31.95,,26.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.39,38,,5.912,percent of total billed charges,38% of total billed charges,6.22,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,0.92,16.54,
ketorolac 30 mg/mL Inj 2 mL Sol [FMC],2559938,CDM,250,RC,J1885,HCPCS,OUTPATIENT,2,ML,12.38,7.428,,10.52,85,,8.416,Percent of total billed charges,85% of total billed charges,0.92,136.6,,40.304,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,2.16,fee schedule,136.60% of BCBS custom fee schedule,4.35,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,1.92,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.7,38,,3.76,percent of total billed charges,38% of total billed charges,3.96,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,0.92,10.52,
ketorolac 30 mg/mL Inj 2 mL Sol [FMC],2559938,CDM,250,RC,J1885,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,23.152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.792,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,53.36,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,0.92,53.36,
ketorolac 30 mg/mL Inj 2 mL Sol [FMC],2559938,CDM,250,RC,J1885,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,234,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.792,percent of total billed charges,35.15% of total billed charges,41.22,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,0.92,41.22,
ketorolac 30 mg/mL Inj 2 mL Sol [FMC],2559938,CDM,250,RC,J1885,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,20.44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.744,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.784,percent of total billed charges,35.15% of total billed charges,44.41,31.95,,0.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.976,percent of total billed charges,31.95% of total billed charges,0.92,44.41,
ketorolac 30 mg/mL Inj 2 mL Sol [FMC],2559938,CDM,250,RC,J1885,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.92,136.6,,33.992,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.872,percent of total billed charges,35.15% of total billed charges,45.05,31.95,,0.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.088,percent of total billed charges,31.95% of total billed charges,0.92,45.05,
ketorolac 30 mg/mL Inj 2 mL Sol [FMC],2559938,CDM,250,RC,J1885,HCPCS,OUTPATIENT,2,ML,24.38,14.628,,20.72,85,,16.576,Percent of total billed charges,85% of total billed charges,0.92,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,1.728,fee schedule,136.60% of BCBS custom fee schedule,8.57,35.15,,26.296,percent of total billed charges,35.15% of total billed charges,55.27,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.26,38,,7.408,percent of total billed charges,38% of total billed charges,7.79,31.95,,23.904,percent of total billed charges,31.95% of total billed charges,0.92,55.27,
ketoconazole Top 2% Crm [FMC],2559946,CDM,250,RC,,,OUTPATIENT,15,EA,426.56,255.936,,362.58,85,,290.064,Percent of total billed charges,85% of total billed charges,213.28,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,213.28,50,,1.728,percent of total billed charges,50% of total billed charges,136.29,31.95,,23.928,percent of total billed charges,31.95% of total billed charges,136.29,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,162.09,38,,129.672,percent of total billed charges,38% of total billed charges,170.62,40,,21.752,percent of total billed charges,40% of total billed charges,136.29,362.58,
ketoconazole Top 2% Crm [FMC],2559946,CDM,250,RC,,,OUTPATIENT,15,EA,100.43,60.258,,85.37,85,,68.296,Percent of total billed charges,85% of total billed charges,50.22,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.22,50,,1.792,percent of total billed charges,50% of total billed charges,32.09,31.95,,179.448,percent of total billed charges,31.95% of total billed charges,32.09,31.95,,179.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.16,38,,30.528,percent of total billed charges,38% of total billed charges,40.17,40,,224.664,percent of total billed charges,40% of total billed charges,32.09,85.37,
ketoconazole Top 2% Crm [FMC],2559946,CDM,250,RC,,,OUTPATIENT,15,EA,426.82,256.092,,362.8,85,,290.24,Percent of total billed charges,85% of total billed charges,213.41,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,213.41,50,,1.2,percent of total billed charges,50% of total billed charges,136.37,31.95,,2.144,percent of total billed charges,31.95% of total billed charges,136.37,31.95,,2.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,162.19,38,,129.752,percent of total billed charges,38% of total billed charges,170.73,40,,2.688,percent of total billed charges,40% of total billed charges,136.37,362.8,
labetalol 5 mg/mL IV 20mL Sol [FMC],2559995,CDM,250,RC,,,OUTPATIENT,20,ML,14.04,8.424,,11.93,85,,9.544,Percent of total billed charges,85% of total billed charges,7.02,50,,3.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.02,50,,1.2,percent of total billed charges,50% of total billed charges,4.49,31.95,,3.168,percent of total billed charges,31.95% of total billed charges,4.49,31.95,,3.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.34,38,,4.272,percent of total billed charges,38% of total billed charges,5.62,40,,3.968,percent of total billed charges,40% of total billed charges,4.49,11.93,
labetalol 5 mg/mL IV 20mL Sol [FMC],2559995,CDM,250,RC,,,OUTPATIENT,20,ML,28.44,17.064,,24.17,85,,19.336,Percent of total billed charges,85% of total billed charges,14.22,50,,3.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.22,50,,1.2,percent of total billed charges,50% of total billed charges,9.09,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,9.09,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.81,38,,8.648,percent of total billed charges,38% of total billed charges,11.38,40,,4.248,percent of total billed charges,40% of total billed charges,9.09,24.17,
labetalol 5 mg/mL IV 20mL Sol [FMC],2559995,CDM,250,RC,,,OUTPATIENT,20,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,3.016,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,1.592,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.632,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,2.04,percent of total billed charges,40% of total billed charges,3.83,10.2,
labetalol 5 mg/mL IV 20mL Sol [FMC],2559995,CDM,250,RC,,,OUTPATIENT,20,ML,44.69,26.814,,37.99,85,,30.392,Percent of total billed charges,85% of total billed charges,22.35,50,,1.744,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.35,50,,2.592,percent of total billed charges,50% of total billed charges,14.28,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,14.28,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.98,38,,13.584,percent of total billed charges,38% of total billed charges,17.88,40,,1.384,percent of total billed charges,40% of total billed charges,14.28,37.99,
labetalol 5 mg/mL IV 20mL Sol [FMC],2559995,CDM,250,RC,,,OUTPATIENT,20,ML,31.2,18.72,,26.52,85,,21.216,Percent of total billed charges,85% of total billed charges,15.6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.6,50,,1.2,percent of total billed charges,50% of total billed charges,9.97,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,9.97,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.86,38,,9.488,percent of total billed charges,38% of total billed charges,12.48,40,,1.304,percent of total billed charges,40% of total billed charges,9.97,26.52,
labetalol 5 mg/mL IV 20mL Sol [FMC],2559995,CDM,250,RC,,,OUTPATIENT,20,ML,101.56,60.936,,86.33,85,,69.064,Percent of total billed charges,85% of total billed charges,50.78,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.78,50,,1.2,percent of total billed charges,50% of total billed charges,32.45,31.95,,1.592,percent of total billed charges,31.95% of total billed charges,32.45,31.95,,1.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.59,38,,30.872,percent of total billed charges,38% of total billed charges,40.62,40,,2,percent of total billed charges,40% of total billed charges,32.45,86.33,
labetalol 5 mg/mL IV 20mL Sol [FMC],2559995,CDM,250,RC,,,OUTPATIENT,20,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,1.2,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.152,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,1.448,percent of total billed charges,40% of total billed charges,3.83,10.2,
labetalol 100 mg Tab [FMC],2560001,CDM,250,RC,,,OUTPATIENT,1,EA,7.41,4.446,,6.3,85,,5.04,Percent of total billed charges,85% of total billed charges,3.71,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.71,50,,2.08,percent of total billed charges,50% of total billed charges,2.37,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,2.37,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.82,38,,2.256,percent of total billed charges,38% of total billed charges,2.96,40,,2.592,percent of total billed charges,40% of total billed charges,2.37,6.3,
labetalol 100 mg Tab [FMC],2560001,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,84.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.896,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.72,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.152,percent of total billed charges,40% of total billed charges,0.96,2.55,
labetalol 100 mg Tab,2560001,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,82.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.776,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.944,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.688,percent of total billed charges,40% of total billed charges,0.96,2.55,
labetalol 100 mg Tab [FMC],2560001,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,19.656,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.776,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.944,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.688,percent of total billed charges,40% of total billed charges,0.96,2.55,
lactobacillus acidophilus and bulgaricus - Gra [FMC],2560068,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,20.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.784,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
lactobacillus acidophilus and bulgaricus - Gra [FMC],2560068,CDM,250,RC,,,OUTPATIENT,1,EA,4.11,2.466,,3.49,85,,2.792,Percent of total billed charges,85% of total billed charges,2.06,50,,20.912,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.06,50,,3.28,percent of total billed charges,50% of total billed charges,1.31,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.31,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.56,38,,1.248,percent of total billed charges,38% of total billed charges,1.64,40,,0.96,percent of total billed charges,40% of total billed charges,1.31,3.49,
lamoTRIgine 100 mg Tab [FMC],2560084,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.776,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.328,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,364.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
lamoTRIgine 100 mg Tab [FMC],2560084,CDM,250,RC,,,OUTPATIENT,1,EA,15.44,9.264,,13.12,85,,10.496,Percent of total billed charges,85% of total billed charges,7.72,50,,2.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.72,50,,4.688,percent of total billed charges,50% of total billed charges,4.93,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,4.93,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.87,38,,4.696,percent of total billed charges,38% of total billed charges,6.18,40,,3.064,percent of total billed charges,40% of total billed charges,4.93,13.12,
lamoTRIgine 100 mg Tab [FMC],2560084,CDM,250,RC,,,OUTPATIENT,1,EA,8.05,4.83,,6.84,85,,5.472,Percent of total billed charges,85% of total billed charges,4.03,50,,2.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.03,50,,1.672,percent of total billed charges,50% of total billed charges,2.57,31.95,,15.2,percent of total billed charges,31.95% of total billed charges,2.57,31.95,,15.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.06,38,,2.448,percent of total billed charges,38% of total billed charges,3.22,40,,19.032,percent of total billed charges,40% of total billed charges,2.57,6.84,
lamoTRIgine 100 mg Tab [FMC],2560084,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.552,percent of total billed charges,50% of total billed charges,0.96,31.95,,15.824,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,15.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,19.808,percent of total billed charges,40% of total billed charges,0.96,2.55,
lamoTRIgine 100 mg Tab [FMC],2560084,CDM,250,RC,,,OUTPATIENT,1,EA,15.44,9.264,,13.12,85,,10.496,Percent of total billed charges,85% of total billed charges,7.72,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.72,50,,1.632,percent of total billed charges,50% of total billed charges,4.93,31.95,,18.992,percent of total billed charges,31.95% of total billed charges,4.93,31.95,,18.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.87,38,,4.696,percent of total billed charges,38% of total billed charges,6.18,40,,23.776,percent of total billed charges,40% of total billed charges,4.93,13.12,
terbinafine 250 mg Tab [FMC],2560092,CDM,250,RC,,,OUTPATIENT,1,EA,42.33,25.398,,35.98,85,,28.784,Percent of total billed charges,85% of total billed charges,21.17,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.17,50,,1.2,percent of total billed charges,50% of total billed charges,13.52,31.95,,30.216,percent of total billed charges,31.95% of total billed charges,13.52,31.95,,30.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.09,38,,12.872,percent of total billed charges,38% of total billed charges,16.93,40,,37.824,percent of total billed charges,40% of total billed charges,13.52,35.98,
terbinafine 250 mg Tab [FMC],2560092,CDM,250,RC,,,OUTPATIENT,1,EA,42.49,25.494,,36.12,85,,28.896,Percent of total billed charges,85% of total billed charges,21.25,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.25,50,,1.72,percent of total billed charges,50% of total billed charges,13.58,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,13.58,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.15,38,,12.92,percent of total billed charges,38% of total billed charges,17,40,,34.568,percent of total billed charges,40% of total billed charges,13.58,36.12,
terbinafine 250 mg Tab [FMC],2560092,CDM,250,RC,,,OUTPATIENT,1,EA,42.33,25.398,,35.98,85,,28.784,Percent of total billed charges,85% of total billed charges,21.17,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.17,50,,1.72,percent of total billed charges,50% of total billed charges,13.52,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,13.52,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.09,38,,12.872,percent of total billed charges,38% of total billed charges,16.93,40,,34.568,percent of total billed charges,40% of total billed charges,13.52,35.98,
terbinafine 250 mg Tab [FMC],2560092,CDM,250,RC,,,OUTPATIENT,1,EA,42.33,25.398,,35.98,85,,28.784,Percent of total billed charges,85% of total billed charges,21.17,50,,19.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.17,50,,1.752,percent of total billed charges,50% of total billed charges,13.52,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,13.52,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.09,38,,12.872,percent of total billed charges,38% of total billed charges,16.93,40,,34.568,percent of total billed charges,40% of total billed charges,13.52,35.98,
lamoTRIgine 25 mg Tab [FMC],2560100,CDM,250,RC,,,OUTPATIENT,1,EA,13.52,8.112,,11.49,85,,9.192,Percent of total billed charges,85% of total billed charges,6.76,50,,72.344,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.76,50,,2.44,percent of total billed charges,50% of total billed charges,4.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.14,38,,4.112,percent of total billed charges,38% of total billed charges,5.41,40,,0.96,percent of total billed charges,40% of total billed charges,4.32,11.49,
lamoTRIgine 25 mg Tab [FMC],2560100,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,75.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.432,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
lamoTRIgine 25 mg Tab [FMC],2560100,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,79.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.824,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
digoxin 250 mcg (0.25mg) Oral Tab [FMC],2560142,CDM,250,RC,,,OUTPATIENT,1,EA,9.36,5.616,,7.96,85,,6.368,Percent of total billed charges,85% of total billed charges,4.68,50,,2.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.68,50,,58.504,percent of total billed charges,50% of total billed charges,2.99,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,2.99,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.56,38,,2.848,percent of total billed charges,38% of total billed charges,3.74,40,,1.28,percent of total billed charges,40% of total billed charges,2.99,7.96,
digoxin 250 mcg (0.25mg) Oral Tab [FMC],2560142,CDM,250,RC,,,OUTPATIENT,1,EA,5.48,3.288,,4.66,85,,3.728,Percent of total billed charges,85% of total billed charges,2.74,50,,1.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.74,50,,20.8,percent of total billed charges,50% of total billed charges,1.75,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.08,38,,1.664,percent of total billed charges,38% of total billed charges,2.19,40,,1.28,percent of total billed charges,40% of total billed charges,1.75,4.66,
digoxin 250 mcg (0.25 mg) Tab [FMC],2560142,CDM,250,RC,,,OUTPATIENT,1,EA,7.48,4.488,,6.36,85,,5.088,Percent of total billed charges,85% of total billed charges,3.74,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.74,50,,291.816,percent of total billed charges,50% of total billed charges,2.39,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,2.39,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.84,38,,2.272,percent of total billed charges,38% of total billed charges,2.99,40,,1.28,percent of total billed charges,40% of total billed charges,2.39,6.36,
insulin glargine 100 units/mL SubQ 10 mL Sol [FMC],2560183,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,110.59,66.354,,94,85,,75.2,Percent of total billed charges,85% of total billed charges,0.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,264.688,fee schedule,136.60% of BCBS custom fee schedule,38.87,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,35.33,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.02,38,,33.616,percent of total billed charges,38% of total billed charges,35.33,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,0.76,94,
levofloxacin 500 mg/100 mL IVPB Premix Sol [FMC],2560241,CDM,250,RC,J1956,HCPCS,OUTPATIENT,100,ML,42.9,25.74,,36.47,85,,29.176,Percent of total billed charges,85% of total billed charges,1.39,136.6,,1.56,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,264.688,fee schedule,136.60% of BCBS custom fee schedule,15.08,35.15,,3.76,fee schedule,35.15% of LA custom fee schedule,13.71,31.95,,3.76,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.3,38,,13.04,percent of total billed charges,38% of total billed charges,13.71,31.95,,4.704,Fee Schedule,31.95% of LA custom fee schedule,1.39,36.47,
levofloxacin 500 mg/100 mL IVPB Premix Sol [FMC],2560241,CDM,250,RC,J1956,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,1.304,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,291.816,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.528,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,3.528,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,4.416,Fee Schedule,31.95% of LA custom fee schedule,1.39,30.6,
levofloxacin 500 mg/100 mL IVPB Premix Sol [FMC],2560241,CDM,250,RC,J1956,HCPCS,OUTPATIENT,100,ML,108.03,64.818,,91.83,85,,73.464,Percent of total billed charges,85% of total billed charges,1.39,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,2.144,fee schedule,136.60% of BCBS custom fee schedule,37.97,35.15,,3.512,fee schedule,35.15% of LA custom fee schedule,34.52,31.95,,3.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.05,38,,32.84,percent of total billed charges,38% of total billed charges,34.52,31.95,,4.4,Fee Schedule,31.95% of LA custom fee schedule,1.39,91.83,
levofloxacin 500 mg/100 mL IVPB Premix Sol [FMC],2560241,CDM,250,RC,J1956,HCPCS,OUTPATIENT,100,ML,48.95,29.37,,41.61,85,,33.288,Percent of total billed charges,85% of total billed charges,1.39,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,1.328,fee schedule,136.60% of BCBS custom fee schedule,17.21,35.15,,3.512,fee schedule,35.15% of LA custom fee schedule,15.64,31.95,,3.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.6,38,,14.88,percent of total billed charges,38% of total billed charges,15.64,31.95,,4.4,Fee Schedule,31.95% of LA custom fee schedule,1.39,41.61,
levofloxacin 500 mg/100 mL IVPB Premix Sol [FMC],2560241,CDM,250,RC,J1956,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,1.336,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,4.752,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,4.752,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,5.952,Fee Schedule,31.95% of LA custom fee schedule,1.39,30.6,
levothyroxine 75 mcg (0.075 mg) Tab [FMC],2560282,CDM,250,RC,,,OUTPATIENT,1,EA,5.58,3.348,,4.74,85,,3.792,Percent of total billed charges,85% of total billed charges,2.79,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.79,50,,2.688,percent of total billed charges,50% of total billed charges,1.78,31.95,,5.304,percent of total billed charges,31.95% of total billed charges,1.78,31.95,,5.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.12,38,,1.696,percent of total billed charges,38% of total billed charges,2.23,40,,6.64,percent of total billed charges,40% of total billed charges,1.78,4.74,
levothyroxine 75 mcg (0.075 mg) Tab [FMC],2560282,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.104,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.168,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.216,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 75 mcg (0.075 mg) Tab [FMC],2560282,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.12,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.872,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.088,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 75 mcg (0.075 mg) Tab [FMC],2560282,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.584,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.424,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.744,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.104,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,3.93,2.358,,3.34,85,,2.672,Percent of total billed charges,85% of total billed charges,1.97,50,,2.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.97,50,,5.744,percent of total billed charges,50% of total billed charges,1.26,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.26,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.49,38,,1.192,percent of total billed charges,38% of total billed charges,1.57,40,,0.96,percent of total billed charges,40% of total billed charges,1.26,3.34,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.776,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.416,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.776,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,23.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.776,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,4.6,2.76,,3.91,85,,3.128,Percent of total billed charges,85% of total billed charges,2.3,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.3,50,,335.144,percent of total billed charges,50% of total billed charges,1.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.75,38,,1.4,percent of total billed charges,38% of total billed charges,1.84,40,,0.96,percent of total billed charges,40% of total billed charges,1.47,3.91,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,20.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1249.248,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,124.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 50 mcg (0.05 mg) Tab [FMC],2560308,CDM,250,RC,,,OUTPATIENT,1,EA,3.1,1.86,,2.64,85,,2.112,Percent of total billed charges,85% of total billed charges,1.55,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.55,50,,420.736,percent of total billed charges,50% of total billed charges,0.99,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.18,38,,0.944,percent of total billed charges,38% of total billed charges,1.24,40,,0.96,percent of total billed charges,40% of total billed charges,0.99,2.64,
levothyroxine 88 mcg (0.088 mg) Tab [FMC],2560324,CDM,250,RC,,,OUTPATIENT,1,EA,5.87,3.522,,4.99,85,,3.992,Percent of total billed charges,85% of total billed charges,2.94,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.94,50,,32.504,percent of total billed charges,50% of total billed charges,1.88,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.88,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.23,38,,1.784,percent of total billed charges,38% of total billed charges,2.35,40,,0.96,percent of total billed charges,40% of total billed charges,1.88,4.99,
levothyroxine 88 mcg (0.088 mg) Tab [FMC],2560324,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,36.12,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 88 mcg (0.088 mg) Tab [FMC],2560324,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,36.08,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
norEPINEPHrine 1 mg/mL IV Sol [FMC],2560332,CDM,250,RC,,,OUTPATIENT,4,ML,32.45,19.47,,27.58,85,,22.064,Percent of total billed charges,85% of total billed charges,16.23,50,,1.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.23,50,,13.264,percent of total billed charges,50% of total billed charges,10.37,31.95,,1,percent of total billed charges,31.95% of total billed charges,10.37,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.33,38,,9.864,percent of total billed charges,38% of total billed charges,12.98,40,,1.248,percent of total billed charges,40% of total billed charges,10.37,27.58,
norEPINEPHrine 1 mg/mL IV Sol [FMC],2560332,CDM,250,RC,,,OUTPATIENT,4,ML,56.55,33.93,,48.07,85,,38.456,Percent of total billed charges,85% of total billed charges,28.28,50,,2.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.28,50,,7.8,percent of total billed charges,50% of total billed charges,18.07,31.95,,1.216,percent of total billed charges,31.95% of total billed charges,18.07,31.95,,1.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.49,38,,17.192,percent of total billed charges,38% of total billed charges,22.62,40,,1.528,percent of total billed charges,40% of total billed charges,18.07,48.07,
norEPINEPHrine 1 mg/mL IV Sol [FMC],2560332,CDM,250,RC,,,OUTPATIENT,4,ML,34.09,20.454,,28.98,85,,23.184,Percent of total billed charges,85% of total billed charges,17.05,50,,2.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.05,50,,8.032,percent of total billed charges,50% of total billed charges,10.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,10.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.95,38,,10.36,percent of total billed charges,38% of total billed charges,13.64,40,,0.96,percent of total billed charges,40% of total billed charges,10.89,28.98,
norEPINEPHrine 1 mg/mL IV Sol [FMC],2560332,CDM,250,RC,,,OUTPATIENT,4,ML,19.5,11.7,,16.58,85,,13.264,Percent of total billed charges,85% of total billed charges,9.75,50,,2.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.75,50,,8.112,percent of total billed charges,50% of total billed charges,6.23,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.23,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.41,38,,5.928,percent of total billed charges,38% of total billed charges,7.8,40,,0.96,percent of total billed charges,40% of total billed charges,6.23,16.58,
norEPINEPHrine 1 mg/mL IV Sol [FMC],2560332,CDM,250,RC,,,OUTPATIENT,4,ML,69.88,41.928,,59.4,85,,47.52,Percent of total billed charges,85% of total billed charges,34.94,50,,2.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34.94,50,,8.584,percent of total billed charges,50% of total billed charges,22.33,31.95,,7.84,percent of total billed charges,31.95% of total billed charges,22.33,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.55,38,,21.24,percent of total billed charges,38% of total billed charges,27.95,40,,7.128,percent of total billed charges,40% of total billed charges,22.33,59.4,
hyoscyamine 0.5 mg/mL Inj Sol [FMC],2560365,CDM,250,RC,J1980,HCPCS,OUTPATIENT,1,ML,118.24,70.944,,100.5,85,,80.4,Percent of total billed charges,85% of total billed charges,53.29,136.6,,1.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.29,136.6,,8.112,fee schedule,136.60% of BCBS custom fee schedule,41.56,35.15,,15.408,percent of total billed charges,35.15% of total billed charges,27.32,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.93,38,,35.944,percent of total billed charges,38% of total billed charges,37.78,31.95,,14.008,percent of total billed charges,31.95% of total billed charges,27.32,100.5,
hyoscyamine 0.5 mg/mL Sol [FMC],2560365,CDM,250,RC,J1980,HCPCS,OUTPATIENT,1,ML,118.24,70.944,,100.5,85,,80.4,Percent of total billed charges,85% of total billed charges,53.29,136.6,,2.088,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.29,136.6,,11.448,fee schedule,136.60% of BCBS custom fee schedule,41.56,35.15,,5.696,percent of total billed charges,35.15% of total billed charges,39.3,31.95,,204.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.93,38,,35.944,percent of total billed charges,38% of total billed charges,37.78,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,37.78,100.5,
hyoscyamine 0.5 mg/mL Sol [FMC],2560365,CDM,250,RC,J1980,HCPCS,OUTPATIENT,1,ML,257.4,154.44,,218.79,85,,175.032,Percent of total billed charges,85% of total billed charges,53.29,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.29,136.6,,2.136,fee schedule,136.60% of BCBS custom fee schedule,90.48,35.15,,3.704,percent of total billed charges,35.15% of total billed charges,139.62,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,97.81,38,,78.248,percent of total billed charges,38% of total billed charges,82.24,31.95,,3.36,percent of total billed charges,31.95% of total billed charges,53.29,218.79,
escitalopram 10 mg Tab UD [FMC],2560373,CDM,250,RC,,,OUTPATIENT,1,EA,14.24,8.544,,12.1,85,,9.68,Percent of total billed charges,85% of total billed charges,7.12,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.12,50,,2.328,percent of total billed charges,50% of total billed charges,4.55,31.95,,1.304,percent of total billed charges,31.95% of total billed charges,4.55,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.41,38,,4.328,percent of total billed charges,38% of total billed charges,5.7,40,,1.184,percent of total billed charges,40% of total billed charges,4.55,12.1,
lidocaine 0.4%-D5W Inj Soln 500 mL premix [FMC],2560381,CDM,250,RC,J2002,HCPCS,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,2.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,2.248,percent of total billed charges,50% of total billed charges,12.65,35.15,,1.504,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,11.5,47.93,
lidocaine 1% Inj 50 ml Sol [FMC],2560399,CDM,250,RC,J2003,HCPCS,OUTPATIENT,50,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,18.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.52,percent of total billed charges,50% of total billed charges,4.22,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,3.83,47.93,
lidocaine 1% Inj 50 ml Sol [FMC],2560399,CDM,250,RC,J2003,HCPCS,OUTPATIENT,50,ML,52.65,31.59,,44.75,85,,35.8,Percent of total billed charges,85% of total billed charges,26.33,50,,4.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.33,50,,1.2,percent of total billed charges,50% of total billed charges,18.51,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.01,38,,16.008,percent of total billed charges,38% of total billed charges,16.82,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,16.82,95.85,
lidocaine 1% Inj 50 ml Sol [FMC],2560399,CDM,250,RC,J2003,HCPCS,OUTPATIENT,50,ML,19.38,11.628,,16.47,85,,13.176,Percent of total billed charges,85% of total billed charges,9.69,50,,4.656,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.69,50,,14.4,percent of total billed charges,50% of total billed charges,6.81,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,143.78,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.36,38,,5.888,percent of total billed charges,38% of total billed charges,6.19,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,6.19,143.78,
lidocaine 1% preservative-free 5 mL Soln ampule [FMC],2560407,CDM,250,RC,J2002,HCPCS,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,63.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,14.4,percent of total billed charges,50% of total billed charges,4.22,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,31.95,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,3.83,31.95,
lidocaine 100 mg preservative-free Soln 5 mL leur lock pf syr [FMC],2560449,CDM,250,RC,J2002,HCPCS,OUTPATIENT,5,ML,26.33,15.798,,22.38,85,,17.904,Percent of total billed charges,85% of total billed charges,13.17,50,,66.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.17,50,,14.4,percent of total billed charges,50% of total billed charges,9.25,35.15,,0.792,percent of total billed charges,35.15% of total billed charges,543.15,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.01,38,,8.008,percent of total billed charges,38% of total billed charges,8.41,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,8.41,543.15,
lidocaine 100 mg preservative-free Soln 5 mL leur lock pf syr [FMC],2560449,CDM,250,RC,J2002,HCPCS,OUTPATIENT,5,ML,16.01,9.606,,13.61,85,,10.888,Percent of total billed charges,85% of total billed charges,8.01,50,,66.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.01,50,,14.4,percent of total billed charges,50% of total billed charges,5.63,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,49.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,5.12,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,5.12,49.84,
lidocaine 100 mg preservative-free Soln 5 mL leur lock pf syr [FMC],2560449,CDM,250,RC,J2002,HCPCS,OUTPATIENT,5,ML,16.7,10.02,,14.2,85,,11.36,Percent of total billed charges,85% of total billed charges,8.35,50,,8.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.35,50,,14.4,percent of total billed charges,50% of total billed charges,5.87,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,32.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.35,38,,5.08,percent of total billed charges,38% of total billed charges,5.34,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,5.34,32.59,
lidocaine Top 5% film [FMC],2560480,CDM,250,RC,,,OUTPATIENT,1,EA,33.4,20.04,,28.39,85,,22.712,Percent of total billed charges,85% of total billed charges,16.7,50,,268.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.7,50,,14.4,percent of total billed charges,50% of total billed charges,10.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,10.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.69,38,,10.152,percent of total billed charges,38% of total billed charges,13.36,40,,0.96,percent of total billed charges,40% of total billed charges,10.67,28.39,
lidocaine Top 5% film [FMC],2560480,CDM,250,RC,,,OUTPATIENT,1,EA,30.42,18.252,,25.86,85,,20.688,Percent of total billed charges,85% of total billed charges,15.21,50,,356.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.21,50,,14.4,percent of total billed charges,50% of total billed charges,9.72,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,9.72,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.56,38,,9.248,percent of total billed charges,38% of total billed charges,12.17,40,,1.104,percent of total billed charges,40% of total billed charges,9.72,25.86,
lincomycin 300 mg/mL Inj Sol [FMC],2560506,CDM,250,RC,J2010,HCPCS,OUTPATIENT,2,ML,88.9,53.34,,75.57,85,,60.456,Percent of total billed charges,85% of total billed charges,16.58,136.6,,8.064,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.58,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,31.25,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,28.4,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.78,38,,27.024,percent of total billed charges,38% of total billed charges,28.4,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,16.58,75.57,
lincomycin 300 mg/mL Inj Sol [FMC]],2560506,CDM,250,RC,J2010,HCPCS,OUTPATIENT,2,ML,102.12,61.272,,86.8,85,,69.44,Percent of total billed charges,85% of total billed charges,16.58,136.6,,1.52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.58,136.6,,1.312,fee schedule,136.60% of BCBS custom fee schedule,35.9,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,32.63,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,38.81,38,,31.048,percent of total billed charges,38% of total billed charges,32.63,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,16.58,86.8,
lincomycin 300 mg/mL Inj Sol [FMC],2560506,CDM,250,RC,J2010,HCPCS,OUTPATIENT,2,ML,79.3,47.58,,67.41,85,,53.928,Percent of total billed charges,85% of total billed charges,16.58,136.6,,1.448,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.58,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,27.87,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,25.34,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.13,38,,24.104,percent of total billed charges,38% of total billed charges,25.34,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,16.58,67.41,
atorvastatin 20 mg Tab [FMC],2560555,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.64,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
atorvastatin 20 mg Tab [FMC],2560555,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.448,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.12,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
atorvastatin 20 mg Tab [FMC],2560555,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.184,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
lithium 150 mg Cap [FMC],2560589,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.448,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,22.816,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
atropine-diphenoxylate 0.025 mg-2.5 mg/5 mL Oral Liq 60 mL [FMC],2560647,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,22.752,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
atropine-diphenoxylate 0.025 mg-2.5 mg Tab [FMC],2560654,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,22.752,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.84,percent of total billed charges,40% of total billed charges,1.28,3.4,
atropine-diphenoxylate 0.025 mg-2.5 mg Tab [FMC],2560654,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,17.064,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.84,percent of total billed charges,40% of total billed charges,1.28,3.4,
atropine-diphenoxylate 0.025 mg-2.5 mg Tab [FMC],2560654,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,21.84,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.84,percent of total billed charges,40% of total billed charges,1.28,3.4,
atropine-diphenoxylate 0.025 mg-2.5 mg Tab [FMC],2560654,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,22.752,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,9.2,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 0.5 mg Tab [FMC],2560688,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,22.752,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,9.2,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 0.5 mg Tab [FMC],2560688,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,135.28,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,9.2,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 0.5 mg Tab [FMC],2560688,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,133.776,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,9.2,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 0.5 mg Tab [FMC],2560688,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,135.28,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,9.2,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 0.5 mg Tab [FMC],2560688,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,9.2,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 1 mg Tab [FMC],2560704,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 1 mg Tab [FMC],2560704,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 1 mg Tab [FMC],2560704,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,2.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.352,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
LORazepam 2 mg/mL Inj Sol [FMC],2560720,CDM,250,RC,J2060,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.52,136.6,,3.376,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.52,136.6,,7.464,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.816,percent of total billed charges,35.15% of total billed charges,53.68,31.95,,0.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.52,53.68,
LORazepam 2 mg/mL Inj Sol [FMC],2560720,CDM,250,RC,J2060,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.52,136.6,,2.472,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.52,136.6,,282.312,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,335.48,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.52,335.48,
LORazepam 2 mg/mL Inj Sol [FMC],2560720,CDM,250,RC,J2060,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.52,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.52,136.6,,238.8,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,19.17,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.52,19.17,
LORazepam 2 mg/mL Inj Sol [FMC],2560720,CDM,250,RC,J2060,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.52,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.52,136.6,,333.456,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,32.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.52,32.59,
LORazepam 2 mg/mL Inj Sol [FMC],2560720,CDM,250,RC,J2060,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.52,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.52,136.6,,17.944,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,28.76,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.52,28.76,
LORazepam 2 mg/mL Inj Sol [FMC],2560720,CDM,250,RC,J2060,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.52,136.6,,1.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.52,136.6,,40.624,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,30.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.52,30.67,
benazepril 10 mg Tab [FMC],2560779,CDM,250,RC,,,OUTPATIENT,1,EA,3.09,1.854,,2.63,85,,2.104,Percent of total billed charges,85% of total billed charges,1.55,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.55,50,,3.544,percent of total billed charges,50% of total billed charges,0.99,31.95,,4.808,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,4.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.17,38,,0.936,percent of total billed charges,38% of total billed charges,1.24,40,,6.016,percent of total billed charges,40% of total billed charges,0.99,2.63,
benazepril 10 mg Tab [FMC],2560779,CDM,250,RC,,,OUTPATIENT,1,EA,3.06,1.836,,2.6,85,,2.08,Percent of total billed charges,85% of total billed charges,1.53,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.53,50,,3.816,percent of total billed charges,50% of total billed charges,0.98,31.95,,4.584,percent of total billed charges,31.95% of total billed charges,0.98,31.95,,4.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.16,38,,0.928,percent of total billed charges,38% of total billed charges,1.22,40,,5.744,percent of total billed charges,40% of total billed charges,0.98,2.6,
benazepril 10 mg Tab [FMC],2560779,CDM,250,RC,,,OUTPATIENT,1,EA,3.41,2.046,,2.9,85,,2.32,Percent of total billed charges,85% of total billed charges,1.71,50,,1.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.71,50,,3.624,percent of total billed charges,50% of total billed charges,1.09,31.95,,4.584,percent of total billed charges,31.95% of total billed charges,1.09,31.95,,4.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.3,38,,1.04,percent of total billed charges,38% of total billed charges,1.36,40,,5.736,percent of total billed charges,40% of total billed charges,1.09,2.9,
enoxaparin 100 mg/1.0 mL SC Sol [FMC],2560860,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,322.87,193.722,,274.44,85,,219.552,Percent of total billed charges,85% of total billed charges,1,136.6,,7.584,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.52,fee schedule,136.60% of BCBS custom fee schedule,113.49,35.15,,4.56,fee schedule,35.15% of LA custom fee schedule,103.16,31.95,,4.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,122.69,38,,98.152,percent of total billed charges,38% of total billed charges,103.16,31.95,,5.712,Fee Schedule,31.95% of LA custom fee schedule,1,274.44,
enoxaparin 100 mg/1.0 mL SC Sol [FMC],2560860,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,322.87,193.722,,274.44,85,,219.552,Percent of total billed charges,85% of total billed charges,1,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,113.49,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,103.16,31.95,,14.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,122.69,38,,98.152,percent of total billed charges,38% of total billed charges,103.16,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,1,274.44,
enoxaparin 100 mg/1.0 mL SC Sol [FMC],2560860,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,264.16,158.496,,224.54,85,,179.632,Percent of total billed charges,85% of total billed charges,1,136.6,,7.168,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.952,fee schedule,136.60% of BCBS custom fee schedule,92.85,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,84.4,31.95,,255.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,100.38,38,,80.304,percent of total billed charges,38% of total billed charges,84.4,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,1,224.54,
enoxaparin 100 mg/1.0 mL SC Sol [FMC],2560860,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,290.26,174.156,,246.72,85,,197.376,Percent of total billed charges,85% of total billed charges,1,136.6,,3.568,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.952,fee schedule,136.60% of BCBS custom fee schedule,102.03,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,92.74,31.95,,255.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110.3,38,,88.24,percent of total billed charges,38% of total billed charges,92.74,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,1,246.72,
enoxaparin 100 mg/1.0 mL SC Sol [FMC],2560860,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,58.5,35.1,,49.73,85,,39.784,Percent of total billed charges,85% of total billed charges,1,136.6,,4.144,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.784,fee schedule,136.60% of BCBS custom fee schedule,20.56,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,18.69,31.95,,276.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.23,38,,17.784,percent of total billed charges,38% of total billed charges,18.69,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,1,49.73,
enoxaparin 100 mg/1.0 mL SC Sol [FMC],2560860,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,90.81,54.486,,77.19,85,,61.752,Percent of total billed charges,85% of total billed charges,1,136.6,,7.288,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.784,fee schedule,136.60% of BCBS custom fee schedule,31.92,35.15,,1.76,fee schedule,35.15% of LA custom fee schedule,29.01,31.95,,1.76,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.51,38,,27.608,percent of total billed charges,38% of total billed charges,29.01,31.95,,2.2,Fee Schedule,31.95% of LA custom fee schedule,1,77.19,
enoxaparin 100 mg/1.0 mL SC Sol [FMC],2560860,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,90.81,54.486,,77.19,85,,61.752,Percent of total billed charges,85% of total billed charges,1,136.6,,104.768,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,31.92,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,29.01,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.51,38,,27.608,percent of total billed charges,38% of total billed charges,29.01,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1,77.19,
enoxaparin 30 mg/0.3 mL SC Sol [FMC],2560878,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,289.94,173.964,,246.45,85,,197.16,Percent of total billed charges,85% of total billed charges,1,136.6,,107.944,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.776,fee schedule,136.60% of BCBS custom fee schedule,101.91,35.15,,2.776,fee schedule,35.15% of LA custom fee schedule,92.64,31.95,,2.776,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110.18,38,,88.144,percent of total billed charges,38% of total billed charges,92.64,31.95,,3.472,Fee Schedule,31.95% of LA custom fee schedule,1,246.45,
enoxaparin 30 mg/0.3 mL Sol [FMC],2560878,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,263.84,158.304,,224.26,85,,179.408,Percent of total billed charges,85% of total billed charges,1,136.6,,1.96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.784,fee schedule,136.60% of BCBS custom fee schedule,92.74,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,84.3,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,100.26,38,,80.208,percent of total billed charges,38% of total billed charges,84.3,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1,224.26,
enoxaparin 30 mg/0.3 mL Sol [FMC],2560878,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,322.51,193.506,,274.13,85,,219.304,Percent of total billed charges,85% of total billed charges,1,136.6,,1.96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,6.24,fee schedule,136.60% of BCBS custom fee schedule,113.36,35.15,,2.44,fee schedule,35.15% of LA custom fee schedule,103.04,31.95,,2.44,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,122.55,38,,98.04,percent of total billed charges,38% of total billed charges,103.04,31.95,,3.056,Fee Schedule,31.95% of LA custom fee schedule,1,274.13,
enoxaparin 30 mg/0.3 mL Sol [FMC],2560878,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,77.61,46.566,,65.97,85,,52.776,Percent of total billed charges,85% of total billed charges,1,136.6,,14.696,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,5.584,fee schedule,136.60% of BCBS custom fee schedule,27.28,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,24.8,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.49,38,,23.592,percent of total billed charges,38% of total billed charges,24.8,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1,65.97,
enoxaparin 30 mg/0.3 mL SC Sol [FMC],2560878,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,58.5,35.1,,49.73,85,,39.784,Percent of total billed charges,85% of total billed charges,1,136.6,,13.864,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,4.992,fee schedule,136.60% of BCBS custom fee schedule,20.56,35.15,,0.816,fee schedule,35.15% of LA custom fee schedule,18.69,31.95,,0.816,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.23,38,,17.784,percent of total billed charges,38% of total billed charges,18.69,31.95,,1.024,Fee Schedule,31.95% of LA custom fee schedule,1,49.73,
enoxaparin 30 mg/0.3 mL SC Sol [FMC],2560878,CDM,250,RC,J1650,HCPCS,OUTPATIENT,1,ML,90.71,54.426,,77.1,85,,61.68,Percent of total billed charges,85% of total billed charges,1,136.6,,8.12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,23.016,fee schedule,136.60% of BCBS custom fee schedule,31.88,35.15,,2.312,fee schedule,35.15% of LA custom fee schedule,28.98,31.95,,2.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.47,38,,27.576,percent of total billed charges,38% of total billed charges,28.98,31.95,,2.896,Fee Schedule,31.95% of LA custom fee schedule,1,77.1,
enoxaparin 60 mg/0.6 mL SC Sol [FMC],2560886,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.6,ML,193.73,116.238,,164.67,85,,131.736,Percent of total billed charges,85% of total billed charges,1,136.6,,10.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,23.016,fee schedule,136.60% of BCBS custom fee schedule,68.1,35.15,,1.552,fee schedule,35.15% of LA custom fee schedule,61.9,31.95,,1.552,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,73.62,38,,58.896,percent of total billed charges,38% of total billed charges,61.9,31.95,,1.944,Fee Schedule,31.95% of LA custom fee schedule,1,164.67,
enoxaparin 60 mg/0.6 mL SC Sol [FMC],2560886,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.6,ML,193.73,116.238,,164.67,85,,131.736,Percent of total billed charges,85% of total billed charges,1,136.6,,3.904,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.216,fee schedule,136.60% of BCBS custom fee schedule,68.1,35.15,,3.976,fee schedule,35.15% of LA custom fee schedule,61.9,31.95,,3.976,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,73.62,38,,58.896,percent of total billed charges,38% of total billed charges,61.9,31.95,,4.984,Fee Schedule,31.95% of LA custom fee schedule,1,164.67,
enoxaparin 60 mg/0.6 mL SC Sol [FMC],2560886,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.6,ML,158.51,95.106,,134.73,85,,107.784,Percent of total billed charges,85% of total billed charges,1,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,55.72,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,50.64,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.23,38,,48.184,percent of total billed charges,38% of total billed charges,50.64,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1,134.73,
enoxaparin 60 mg/0.6 mL SC Sol [FMC],2560886,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.6,ML,174.16,104.496,,148.04,85,,118.432,Percent of total billed charges,85% of total billed charges,1,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,4.68,fee schedule,136.60% of BCBS custom fee schedule,61.22,35.15,,4.024,fee schedule,35.15% of LA custom fee schedule,55.64,31.95,,4.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,66.18,38,,52.944,percent of total billed charges,38% of total billed charges,55.64,31.95,,5.04,Fee Schedule,31.95% of LA custom fee schedule,1,148.04,
enoxaparin 60 mg/0.6 mL SC Sol [FMC],2560886,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.6,ML,54.49,32.694,,46.32,85,,37.056,Percent of total billed charges,85% of total billed charges,1,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,19.15,35.15,,3.976,fee schedule,35.15% of LA custom fee schedule,17.41,31.95,,3.976,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.71,38,,16.568,percent of total billed charges,38% of total billed charges,17.41,31.95,,4.976,Fee Schedule,31.95% of LA custom fee schedule,1,46.32,
Dextrose 5% in Lactated Ringers IV Sol 1000 mL [FMC],2560902,CDM,250,RC,J7120,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.69,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.69,136.6,,1.376,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,4.024,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,4.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,5.04,Fee Schedule,31.95% of LA custom fee schedule,3.69,30.6,
Lactated Ringers 1000 mL IV Sol [FMC],2560902,CDM,250,RC,J7120,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.69,136.6,,4.232,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.69,136.6,,1.264,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,276.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,3.69,30.6,
Lactated Ringers 1000 mL IV Sol [FMC],2560902,CDM,250,RC,J7120,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.69,136.6,,4.232,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.69,136.6,,6.96,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,278.608,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,3.69,30.6,
Lactated Ringers 1000 mL IV Sol [FMC],2560902,CDM,250,RC,J7120,HCPCS,OUTPATIENT,1000,ML,36.92,22.152,,31.38,85,,25.104,Percent of total billed charges,85% of total billed charges,3.69,136.6,,4.352,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.69,136.6,,6.96,fee schedule,136.60% of BCBS custom fee schedule,12.98,35.15,,7.952,fee schedule,35.15% of LA custom fee schedule,11.8,31.95,,7.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.03,38,,11.224,percent of total billed charges,38% of total billed charges,11.8,31.95,,9.96,Fee Schedule,31.95% of LA custom fee schedule,3.69,31.38,
Lactated Ringers 500 mL IV Sol [FMC],2560910,CDM,250,RC,J7120,HCPCS,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.69,136.6,,3.344,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.69,136.6,,23.016,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,4.648,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,4.648,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,5.824,Fee Schedule,31.95% of LA custom fee schedule,3.69,30.6,
PHENobarbital 65 mg/mL Inj Sol [FMC],2560944,CDM,250,RC,J2560,HCPCS,OUTPATIENT,1,ML,93.52,56.112,,79.49,85,,63.592,Percent of total billed charges,85% of total billed charges,54.48,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.48,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,32.87,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,48.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.54,38,,28.432,percent of total billed charges,38% of total billed charges,29.88,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,29.88,79.49,
PHENobarbital 65 mg/mL Inj Sol [FMC],2560944,CDM,250,RC,J2560,HCPCS,OUTPATIENT,1,ML,85.1,51.06,,72.34,85,,57.872,Percent of total billed charges,85% of total billed charges,54.48,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.48,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,29.91,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,431.33,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.34,38,,25.872,percent of total billed charges,38% of total billed charges,27.19,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,27.19,431.33,
bimatoprost ophthalmic 0.01% Sol [FMC],2560951,CDM,250,RC,,,OUTPATIENT,2.5,EA,702.07,421.242,,596.76,85,,477.408,Percent of total billed charges,85% of total billed charges,351.04,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,351.04,50,,1.2,percent of total billed charges,50% of total billed charges,224.31,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,224.31,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,266.79,38,,213.432,percent of total billed charges,38% of total billed charges,280.83,40,,0.96,percent of total billed charges,40% of total billed charges,224.31,596.76,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap UD [FMC],2561009,CDM,250,RC,,,OUTPATIENT,1,EA,8.4,5.04,,7.14,85,,5.712,Percent of total billed charges,85% of total billed charges,4.2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.2,50,,1.2,percent of total billed charges,50% of total billed charges,2.68,31.95,,0.776,percent of total billed charges,31.95% of total billed charges,2.68,31.95,,0.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.19,38,,2.552,percent of total billed charges,38% of total billed charges,3.36,40,,0.976,percent of total billed charges,40% of total billed charges,2.68,7.14,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap UD [FMC],2561009,CDM,250,RC,,,OUTPATIENT,1,EA,12.4,7.44,,10.54,85,,8.432,Percent of total billed charges,85% of total billed charges,6.2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.2,50,,2.184,percent of total billed charges,50% of total billed charges,3.96,31.95,,1.568,percent of total billed charges,31.95% of total billed charges,3.96,31.95,,1.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.71,38,,3.768,percent of total billed charges,38% of total billed charges,4.96,40,,1.968,percent of total billed charges,40% of total billed charges,3.96,10.54,
nitrofurantoin macrocrystals-monohydrate 100 mg Cap UD [FMC],2561009,CDM,250,RC,,,OUTPATIENT,1,EA,13.27,7.962,,11.28,85,,9.024,Percent of total billed charges,85% of total billed charges,6.64,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.64,50,,2.272,percent of total billed charges,50% of total billed charges,4.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.04,38,,4.032,percent of total billed charges,38% of total billed charges,5.31,40,,0.96,percent of total billed charges,40% of total billed charges,4.24,11.28,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,6.37,3.822,,5.41,85,,4.328,Percent of total billed charges,85% of total billed charges,3.19,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.19,50,,1.336,percent of total billed charges,50% of total billed charges,2.04,31.95,,219.8,percent of total billed charges,31.95% of total billed charges,2.04,31.95,,219.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.42,38,,1.936,percent of total billed charges,38% of total billed charges,2.55,40,,275.184,percent of total billed charges,40% of total billed charges,2.04,5.41,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,4.32,2.592,,3.67,85,,2.936,Percent of total billed charges,85% of total billed charges,2.16,50,,3.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.16,50,,2.24,percent of total billed charges,50% of total billed charges,1.38,31.95,,7.56,percent of total billed charges,31.95% of total billed charges,1.38,31.95,,7.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.64,38,,1.312,percent of total billed charges,38% of total billed charges,1.73,40,,9.464,percent of total billed charges,40% of total billed charges,1.38,3.67,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,4.07,2.442,,3.46,85,,2.768,Percent of total billed charges,85% of total billed charges,2.04,50,,4.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.04,50,,57.2,percent of total billed charges,50% of total billed charges,1.3,31.95,,10.08,percent of total billed charges,31.95% of total billed charges,1.3,31.95,,10.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.55,38,,1.24,percent of total billed charges,38% of total billed charges,1.63,40,,12.624,percent of total billed charges,40% of total billed charges,1.3,3.46,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,6.24,3.744,,5.3,85,,4.24,Percent of total billed charges,85% of total billed charges,3.12,50,,1.808,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.12,50,,1.2,percent of total billed charges,50% of total billed charges,1.99,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.99,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.37,38,,1.896,percent of total billed charges,38% of total billed charges,2.5,40,,0.96,percent of total billed charges,40% of total billed charges,1.99,5.3,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,4.52,2.712,,3.84,85,,3.072,Percent of total billed charges,85% of total billed charges,2.26,50,,2.32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.26,50,,1.2,percent of total billed charges,50% of total billed charges,1.44,31.95,,0.976,percent of total billed charges,31.95% of total billed charges,1.44,31.95,,0.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.72,38,,1.376,percent of total billed charges,38% of total billed charges,1.81,40,,1.224,percent of total billed charges,40% of total billed charges,1.44,3.84,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,8.11,4.866,,6.89,85,,5.512,Percent of total billed charges,85% of total billed charges,4.06,50,,3.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.06,50,,8.856,percent of total billed charges,50% of total billed charges,2.59,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,2.59,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.08,38,,2.464,percent of total billed charges,38% of total billed charges,3.24,40,,1.392,percent of total billed charges,40% of total billed charges,2.59,6.89,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,6.73,4.038,,5.72,85,,4.576,Percent of total billed charges,85% of total billed charges,3.37,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.37,50,,5.672,percent of total billed charges,50% of total billed charges,2.15,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,2.15,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.56,38,,2.048,percent of total billed charges,38% of total billed charges,2.69,40,,1.288,percent of total billed charges,40% of total billed charges,2.15,5.72,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,11.53,6.918,,9.8,85,,7.84,Percent of total billed charges,85% of total billed charges,5.77,50,,3.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.77,50,,9.048,percent of total billed charges,50% of total billed charges,3.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.38,38,,3.504,percent of total billed charges,38% of total billed charges,4.61,40,,0.96,percent of total billed charges,40% of total billed charges,3.68,9.8,
magnesium citrate 1.745 g/ 296ml Liq [FMC],2561041,CDM,250,RC,,,OUTPATIENT,296,UN,11.53,6.918,,9.8,85,,7.84,Percent of total billed charges,85% of total billed charges,5.77,50,,331.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.77,50,,9.04,percent of total billed charges,50% of total billed charges,3.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.38,38,,3.504,percent of total billed charges,38% of total billed charges,4.61,40,,0.96,percent of total billed charges,40% of total billed charges,3.68,9.8,
magnesium oxide 400mg Tab UD [FMC],2561058,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,35.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.376,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
magnesium oxide 400mg Tab UD [FMC],2561058,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.872,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.376,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.032,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,278.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.664,percent of total billed charges,40% of total billed charges,0.96,2.55,
mannitol 25% IV Sol 50 mL [FMC],2561090,CDM,250,RC,J2150,HCPCS,OUTPATIENT,50,ML,18.95,11.37,,16.11,85,,12.888,Percent of total billed charges,85% of total billed charges,7.91,136.6,,3.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.91,136.6,,2.376,fee schedule,136.60% of BCBS custom fee schedule,6.66,35.15,,0.888,percent of total billed charges,35.15% of total billed charges,455.29,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.2,38,,5.76,percent of total billed charges,38% of total billed charges,6.05,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,6.05,455.29,
mannitol 25% Sol,2561090,CDM,250,RC,J2150,HCPCS,OUTPATIENT,50,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,7.91,136.6,,19.792,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.91,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.88,percent of total billed charges,35.15% of total billed charges,31.95,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,3.83,31.95,
mannitol 20% IV Sol 500 mL [FMC],2561108,CDM,250,RC,,,OUTPATIENT,500,ML,59.48,35.688,,50.56,85,,40.448,Percent of total billed charges,85% of total billed charges,29.74,50,,19.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.74,50,,1.952,percent of total billed charges,50% of total billed charges,19,31.95,,0.824,percent of total billed charges,31.95% of total billed charges,19,31.95,,0.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.6,38,,18.08,percent of total billed charges,38% of total billed charges,23.79,40,,1.024,percent of total billed charges,40% of total billed charges,19,50.56,
mannitol 20% IV Sol 500 mL [FMC],2561108,CDM,250,RC,,,OUTPATIENT,500,ML,61.91,37.146,,52.62,85,,42.096,Percent of total billed charges,85% of total billed charges,30.96,50,,46.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.96,50,,1.2,percent of total billed charges,50% of total billed charges,19.78,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,19.78,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.53,38,,18.824,percent of total billed charges,38% of total billed charges,24.76,40,,1.104,percent of total billed charges,40% of total billed charges,19.78,52.62,
mannitol 20% IV Sol 500 mL [FMC],2561108,CDM,250,RC,,,OUTPATIENT,500,ML,74.3,44.58,,63.16,85,,50.528,Percent of total billed charges,85% of total billed charges,37.15,50,,8.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.15,50,,1.2,percent of total billed charges,50% of total billed charges,23.74,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,23.74,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.23,38,,22.584,percent of total billed charges,38% of total billed charges,29.72,40,,1.392,percent of total billed charges,40% of total billed charges,23.74,63.16,
rizatriptan 10 mg Dis Tab [FMC],2561173,CDM,250,RC,,,OUTPATIENT,1,EA,118.21,70.926,,100.48,85,,80.384,Percent of total billed charges,85% of total billed charges,59.11,50,,8.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,59.11,50,,24.184,percent of total billed charges,50% of total billed charges,37.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,37.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.92,38,,35.936,percent of total billed charges,38% of total billed charges,47.28,40,,0.96,percent of total billed charges,40% of total billed charges,37.77,100.48,
rizatriptan 10 mg Dis Tab [FMC],2561173,CDM,250,RC,,,OUTPATIENT,1,EA,108.02,64.812,,91.82,85,,73.456,Percent of total billed charges,85% of total billed charges,54.01,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,54.01,50,,6.24,percent of total billed charges,50% of total billed charges,34.51,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,34.51,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.05,38,,32.84,percent of total billed charges,38% of total billed charges,43.21,40,,1.392,percent of total billed charges,40% of total billed charges,34.51,91.82,
rizatriptan 10 mg DIS [FMC],2561173,CDM,250,RC,,,OUTPATIENT,1,EA,108.02,64.812,,91.82,85,,73.456,Percent of total billed charges,85% of total billed charges,54.01,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,54.01,50,,19.784,percent of total billed charges,50% of total billed charges,34.51,31.95,,10.712,percent of total billed charges,31.95% of total billed charges,34.51,31.95,,10.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.05,38,,32.84,percent of total billed charges,38% of total billed charges,43.21,40,,13.416,percent of total billed charges,40% of total billed charges,34.51,91.82,
rizatriptan 10 mg DIS [FMC],2561173,CDM,250,RC,,,OUTPATIENT,1,EA,108.02,64.812,,91.82,85,,73.456,Percent of total billed charges,85% of total billed charges,54.01,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,54.01,50,,21.984,percent of total billed charges,50% of total billed charges,34.51,31.95,,45.896,percent of total billed charges,31.95% of total billed charges,34.51,31.95,,45.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.05,38,,32.84,percent of total billed charges,38% of total billed charges,43.21,40,,57.456,percent of total billed charges,40% of total billed charges,34.51,91.82,
cefepime 1 g Inj [FMC],2561199,CDM,250,RC,J0692,HCPCS,OUTPATIENT,1,EA,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,1.91,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.91,136.6,,10.928,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,47.312,fee schedule,35.15% of LA custom fee schedule,7.48,31.95,,47.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,59.232,Fee Schedule,31.95% of LA custom fee schedule,1.91,19.89,
cefepime 1 g Inj [FMC],2561199,CDM,250,RC,J0692,HCPCS,OUTPATIENT,1,EA,22.23,13.338,,18.9,85,,15.12,Percent of total billed charges,85% of total billed charges,1.91,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.91,136.6,,12.568,fee schedule,136.60% of BCBS custom fee schedule,7.81,35.15,,43.648,fee schedule,35.15% of LA custom fee schedule,7.1,31.95,,43.648,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.45,38,,6.76,percent of total billed charges,38% of total billed charges,7.1,31.95,,54.64,Fee Schedule,31.95% of LA custom fee schedule,1.91,18.9,
cefepime 1 g Inj [FMC],2561199,CDM,250,RC,J0692,HCPCS,OUTPATIENT,1,EA,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,1.91,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.91,136.6,,29.664,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,47.312,fee schedule,35.15% of LA custom fee schedule,7.48,31.95,,47.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,59.232,Fee Schedule,31.95% of LA custom fee schedule,1.91,19.89,
hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab[FMC],2561207,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,19.288,percent of total billed charges,50% of total billed charges,0.96,31.95,,16.496,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,16.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,20.656,percent of total billed charges,40% of total billed charges,0.96,2.55,
meclizine 12.5 mg Tab [FMC],2561231,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,36.552,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,36.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,45.76,percent of total billed charges,40% of total billed charges,1.28,3.4,
meclizine 12.5 mg Tab [FMC],2561231,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.208,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,291.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.064,percent of total billed charges,40% of total billed charges,1.28,3.4,
meclizine 12.5 mg Tab [FMC],2561231,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,298.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.064,percent of total billed charges,40% of total billed charges,1.28,3.4,
meclizine 12.5 mg Tab [FMC],2561231,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,298.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.064,percent of total billed charges,40% of total billed charges,1.28,3.4,
meclizine 12.5 mg Tab [FMC],2561231,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,299.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.064,percent of total billed charges,40% of total billed charges,1.28,3.4,
meclizine 12.5 mg Tabmeclizine 12.5 mg Tab [FMC],2561231,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,3.656,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.544,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,4.44,percent of total billed charges,40% of total billed charges,1.28,3.4,
megestrol 40 mg/mL Susp 400 mg/10 mL [FMC],2561280,CDM,250,RC,,,OUTPATIENT,10,ML,14.71,8.826,,12.5,85,,10,Percent of total billed charges,85% of total billed charges,7.36,50,,4.872,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.36,50,,1.2,percent of total billed charges,50% of total billed charges,4.7,31.95,,1.944,percent of total billed charges,31.95% of total billed charges,4.7,31.95,,1.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.59,38,,4.472,percent of total billed charges,38% of total billed charges,5.88,40,,2.44,percent of total billed charges,40% of total billed charges,4.7,12.5,
megestrol 40 mg/mL Susp 400 mg/10 mL [FMC],2561280,CDM,250,RC,,,OUTPATIENT,10,ML,13.81,8.286,,11.74,85,,9.392,Percent of total billed charges,85% of total billed charges,6.91,50,,5.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.91,50,,1.2,percent of total billed charges,50% of total billed charges,4.41,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.41,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.25,38,,4.2,percent of total billed charges,38% of total billed charges,5.52,40,,0.96,percent of total billed charges,40% of total billed charges,4.41,11.74,
megestrol 40 mg/mL Susp 400 mg/10 mL [FMC],2561280,CDM,250,RC,,,OUTPATIENT,10,ML,13.74,8.244,,11.68,85,,9.344,Percent of total billed charges,85% of total billed charges,6.87,50,,2.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.87,50,,1.2,percent of total billed charges,50% of total billed charges,4.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.22,38,,4.176,percent of total billed charges,38% of total billed charges,5.5,40,,0.96,percent of total billed charges,40% of total billed charges,4.39,11.68,
megestrol 40 mg/mL Susp 400 mg/10 mL [FMC],2561280,CDM,250,RC,,,OUTPATIENT,10,ML,13.74,8.244,,11.68,85,,9.344,Percent of total billed charges,85% of total billed charges,6.87,50,,2.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.87,50,,1.2,percent of total billed charges,50% of total billed charges,4.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.22,38,,4.176,percent of total billed charges,38% of total billed charges,5.5,40,,0.96,percent of total billed charges,40% of total billed charges,4.39,11.68,
megestrol 40 mg/mL Susp 400 mg/10 mL [FMC],2561280,CDM,250,RC,,,OUTPATIENT,10,ML,18.59,11.154,,15.8,85,,12.64,Percent of total billed charges,85% of total billed charges,9.3,50,,62.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.3,50,,1.2,percent of total billed charges,50% of total billed charges,5.94,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.94,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.06,38,,5.648,percent of total billed charges,38% of total billed charges,7.44,40,,0.96,percent of total billed charges,40% of total billed charges,5.94,15.8,
megestrol 40 mg/mL Susp 400 mg/10 mL [FMC],2561280,CDM,250,RC,,,OUTPATIENT,10,ML,20.75,12.45,,17.64,85,,14.112,Percent of total billed charges,85% of total billed charges,10.38,50,,6.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.38,50,,101.496,percent of total billed charges,50% of total billed charges,6.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.89,38,,6.312,percent of total billed charges,38% of total billed charges,8.3,40,,0.96,percent of total billed charges,40% of total billed charges,6.63,17.64,
megestrol 40 mg/mL Susp 400 mg/10 mL [FMC],2561280,CDM,250,RC,,,OUTPATIENT,10,ML,16.3,9.78,,13.86,85,,11.088,Percent of total billed charges,85% of total billed charges,8.15,50,,13.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.15,50,,71.92,percent of total billed charges,50% of total billed charges,5.21,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.21,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.19,38,,4.952,percent of total billed charges,38% of total billed charges,6.52,40,,0.96,percent of total billed charges,40% of total billed charges,5.21,13.86,
megestrol 40 mg Tab [FMC],2561306,CDM,250,RC,,,OUTPATIENT,1,EA,3.4,2.04,,2.89,85,,2.312,Percent of total billed charges,85% of total billed charges,1.7,50,,10.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.7,50,,8.176,percent of total billed charges,50% of total billed charges,1.09,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.09,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.29,38,,1.032,percent of total billed charges,38% of total billed charges,1.36,40,,0.96,percent of total billed charges,40% of total billed charges,1.09,2.89,
megestrol 40 mg Tab [FMC],2561306,CDM,250,RC,,,OUTPATIENT,1,EA,4.44,2.664,,3.77,85,,3.016,Percent of total billed charges,85% of total billed charges,2.22,50,,9.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.22,50,,8.176,percent of total billed charges,50% of total billed charges,1.42,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,1.42,31.95,,1.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.69,38,,1.352,percent of total billed charges,38% of total billed charges,1.78,40,,1.408,percent of total billed charges,40% of total billed charges,1.42,3.77,
megestrol 40 mg Tab [FMC],2561306,CDM,250,RC,,,OUTPATIENT,1,EA,3.45,2.07,,2.93,85,,2.344,Percent of total billed charges,85% of total billed charges,1.73,50,,17.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.73,50,,1.2,percent of total billed charges,50% of total billed charges,1.1,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.1,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,0.96,percent of total billed charges,40% of total billed charges,1.1,2.93,
megestrol 40 mg Tab [FMC],2561306,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,17.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.272,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.728,percent of total billed charges,40% of total billed charges,0.96,2.55,
megestrol 40 mg Tab [FMC],2561306,CDM,250,RC,,,OUTPATIENT,1,EA,5.55,3.33,,4.72,85,,3.776,Percent of total billed charges,85% of total billed charges,2.78,50,,14.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.78,50,,1.2,percent of total billed charges,50% of total billed charges,1.77,31.95,,1.144,percent of total billed charges,31.95% of total billed charges,1.77,31.95,,1.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.11,38,,1.688,percent of total billed charges,38% of total billed charges,2.22,40,,1.432,percent of total billed charges,40% of total billed charges,1.77,4.72,
melatonin 3 mg Tab [FMC],2561322,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.24,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
melatonin 3 mg Tab [FMC],2561322,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.392,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg Tab [FMC],2561421,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.264,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg Tab [FMC],2561421,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.296,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.384,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg Tab [FMC],2561421,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.608,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.384,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg Tab [FMC],2561421,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.144,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.432,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg Tab [FMC],2561421,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 500 mg Tab [FMC],2561421,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 850 mg Tab [FMC],2561439,CDM,250,RC,,,OUTPATIENT,1,EA,3.91,2.346,,3.32,85,,2.656,Percent of total billed charges,85% of total billed charges,1.96,50,,1.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.96,50,,1.2,percent of total billed charges,50% of total billed charges,1.25,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.25,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.49,38,,1.192,percent of total billed charges,38% of total billed charges,1.56,40,,0.96,percent of total billed charges,40% of total billed charges,1.25,3.32,
metFORMIN 850 mg Tab [FMC],2561439,CDM,250,RC,,,OUTPATIENT,1,EA,4.77,2.862,,4.05,85,,3.24,Percent of total billed charges,85% of total billed charges,2.39,50,,3.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.39,50,,17.416,percent of total billed charges,50% of total billed charges,1.52,31.95,,1.016,percent of total billed charges,31.95% of total billed charges,1.52,31.95,,1.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.81,38,,1.448,percent of total billed charges,38% of total billed charges,1.91,40,,1.272,percent of total billed charges,40% of total billed charges,1.52,4.05,
metFORMIN 850 mg Tab [FMC],2561439,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,16.36,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.656,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.072,percent of total billed charges,40% of total billed charges,0.96,2.55,
metFORMIN 850 mg Tab,2561439,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,275.032,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
methylergonovine 0.2 mg/mL Inj Sol [FMC],2561447,CDM,250,RC,J2210,HCPCS,OUTPATIENT,1,ML,27.88,16.728,,23.7,85,,18.96,Percent of total billed charges,85% of total billed charges,31.69,136.6,,1.928,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,31.69,136.6,,58.632,fee schedule,136.60% of BCBS custom fee schedule,9.8,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,223.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.59,38,,8.472,percent of total billed charges,38% of total billed charges,8.91,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,8.91,223.65,
methylergonovine 0.2 mg/mL Inj Sol [FMC],2561447,CDM,250,RC,J2210,HCPCS,OUTPATIENT,1,ML,54.8,32.88,,46.58,85,,37.264,Percent of total billed charges,85% of total billed charges,31.69,136.6,,3.528,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,31.69,136.6,,1.24,fee schedule,136.60% of BCBS custom fee schedule,19.26,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.82,38,,16.656,percent of total billed charges,38% of total billed charges,17.51,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,17.51,47.93,
methotrexate 2.5 mg Tab [FMC],2561488,CDM,250,RC,J8610,HCPCS,OUTPATIENT,1,EA,20.27,12.162,,17.23,85,,13.784,Percent of total billed charges,85% of total billed charges,0.4,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.4,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,7.12,35.15,,1.328,percent of total billed charges,35.15% of total billed charges,255.6,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.7,38,,6.16,percent of total billed charges,38% of total billed charges,6.48,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,0.4,255.6,
methotrexate 2.5 mg Tab [FMC],2561488,CDM,250,RC,J8610,HCPCS,OUTPATIENT,1,EA,13.16,7.896,,11.19,85,,8.952,Percent of total billed charges,85% of total billed charges,0.4,136.6,,2.856,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.4,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.63,35.15,,1.848,percent of total billed charges,35.15% of total billed charges,115.02,31.95,,1.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5,38,,4,percent of total billed charges,38% of total billed charges,4.2,31.95,,2.32,percent of total billed charges,31.95% of total billed charges,0.4,115.02,
methylPREDNISolone 4 mg Tab [FMC],2561512,CDM,250,RC,J7509,HCPCS,OUTPATIENT,1,EA,4.64,2.784,,3.94,85,,3.152,Percent of total billed charges,85% of total billed charges,0.36,136.6,,17.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.36,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1.63,35.15,,1.768,percent of total billed charges,35.15% of total billed charges,15.98,31.95,,1.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.76,38,,1.408,percent of total billed charges,38% of total billed charges,1.48,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,0.36,15.98,
methylPREDNISolone 4 mg Tab [FMC],2561512,CDM,250,RC,J7509,HCPCS,OUTPATIENT,1,EA,5.36,3.216,,4.56,85,,3.648,Percent of total billed charges,85% of total billed charges,0.36,136.6,,1.976,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.36,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1.88,35.15,,1.768,percent of total billed charges,35.15% of total billed charges,958.5,31.95,,1.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.04,38,,1.632,percent of total billed charges,38% of total billed charges,1.71,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,0.36,958.5,
methocarbamol 500 mg Tab [FMC],2561538,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.224,percent of total billed charges,40% of total billed charges,0.96,2.55,
methocarbamol 500 mg Tab [FMC],2561538,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.096,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.624,percent of total billed charges,40% of total billed charges,0.96,2.55,
methocarbamol 500 mg Tab [FMC],2561538,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.216,percent of total billed charges,40% of total billed charges,0.96,2.55,
methocarbamol 500 mg Tab [FMC],2561538,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.056,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.992,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.744,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoclopramide 10mg/2ml Sol inj [FMC],2561587,CDM,250,RC,J2765,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.67,136.6,,17.744,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.67,136.6,,7.84,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.072,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.072,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.336,Fee Schedule,31.95% of LA custom fee schedule,1.67,10.2,
metoclopramide 5 mg/mL Sol 2 mL [FMC],2561587,CDM,250,RC,J2765,HCPCS,OUTPATIENT,1,ML,13.07,7.842,,11.11,85,,8.888,Percent of total billed charges,85% of total billed charges,1.67,136.6,,15.216,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.67,136.6,,7.92,fee schedule,136.60% of BCBS custom fee schedule,4.59,35.15,,1.632,fee schedule,35.15% of LA custom fee schedule,4.18,31.95,,1.632,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.97,38,,3.976,percent of total billed charges,38% of total billed charges,4.18,31.95,,2.04,Fee Schedule,31.95% of LA custom fee schedule,1.67,11.11,
metoclopramide 5 mg/mL Sol 2 mL [FMC],2561587,CDM,250,RC,J2765,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.67,136.6,,9.048,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.67,136.6,,11.056,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.04,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.304,Fee Schedule,31.95% of LA custom fee schedule,1.67,10.2,
metoclopramide 5 mg/mL Sol 2 mL [FMC],2561587,CDM,250,RC,J2765,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.67,136.6,,1.552,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.67,136.6,,7.92,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1.67,10.2,
metoclopramide 5 mg/mL Sol 2 mL [FMC],2561587,CDM,250,RC,J2765,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.67,136.6,,1.552,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.67,136.6,,6.504,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.096,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.096,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.376,Fee Schedule,31.95% of LA custom fee schedule,1.67,10.2,
metoclopramide 10mg/2ml Sol inj [FMC],2561587,CDM,250,RC,J2765,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.67,136.6,,2.632,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.67,136.6,,6.848,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.096,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.096,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.376,Fee Schedule,31.95% of LA custom fee schedule,1.67,10.2,
metoclopramide 10mg/2ml Sol inj [FMC],2561587,CDM,250,RC,J2765,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.67,136.6,,1.536,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.67,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.12,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.4,Fee Schedule,31.95% of LA custom fee schedule,1.67,10.2,
metoclopramide 10 mg Tab [FMC],2561595,CDM,250,RC,,,OUTPATIENT,1,EA,3.11,1.866,,2.64,85,,2.112,Percent of total billed charges,85% of total billed charges,1.56,50,,4.368,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.56,50,,1.2,percent of total billed charges,50% of total billed charges,0.99,31.95,,1.56,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,1.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.18,38,,0.944,percent of total billed charges,38% of total billed charges,1.24,40,,1.952,percent of total billed charges,40% of total billed charges,0.99,2.64,
metoclopramide 10 mg Tab [FMC],2561595,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.312,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.552,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.944,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoclopramide 10 mg Tab [FMC],2561595,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,67.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.808,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.256,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoclopramide 5 mg/5 mL Oral Syrup [FMC],2561603,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,67.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,37.384,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,37.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,46.8,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoclopramide 5 mg/5 mL Oral Syrup [FMC],2561603,CDM,250,RC,,,OUTPATIENT,5,ML,3.46,2.076,,2.94,85,,2.352,Percent of total billed charges,85% of total billed charges,1.73,50,,25.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.73,50,,1.2,percent of total billed charges,50% of total billed charges,1.11,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,16.64,percent of total billed charges,40% of total billed charges,1.11,2.94,
metoprolol tartrate 50 mg UD Tab [FMC],2561611,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.512,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,186.464,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,186.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,233.448,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol tartrate 50 mg UD Tab [FMC],2561611,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.088,percent of total billed charges,50% of total billed charges,0.96,31.95,,169.136,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,169.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,211.744,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol tartrate 50 mg UD Tab [FMC],2561611,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.488,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,169.136,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,169.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,211.744,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol tartrate 50 mg UD Tab [FMC],2561611,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.488,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.304,percent of total billed charges,50% of total billed charges,0.96,31.95,,186.464,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,186.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,233.448,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol 50 mg Tab,2561611,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.712,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol 1 mg/mL Inj Sol [FMC],2561629,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,5.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,1.392,percent of total billed charges,50% of total billed charges,3.83,31.95,,0.848,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,0.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,1.064,percent of total billed charges,40% of total billed charges,3.83,10.2,
metoprolol 1 mg/mL Inj Sol [FMC],2561629,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,10.016,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,9.336,percent of total billed charges,50% of total billed charges,3.83,31.95,,0.856,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,0.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,1.072,percent of total billed charges,40% of total billed charges,3.83,10.2,
metoprolol 1 mg/mL Inj Sol [FMC],2561629,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,7.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,5.048,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.712,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,2.144,percent of total billed charges,40% of total billed charges,3.83,10.2,
metoprolol 1 mg/mL Inj Sol [FMC],2561629,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,6.448,percent of total billed charges,50% of total billed charges,3.83,31.95,,2.616,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,2.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,3.28,percent of total billed charges,40% of total billed charges,3.83,10.2,
metoprolol 1 mg/mL Inj Sol [FMC],2561629,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,10.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,15.328,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.992,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,2.496,percent of total billed charges,40% of total billed charges,3.83,10.2,
metoprolol 1 mg/mL Inj Sol [FMC],2561629,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,10.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,11.16,percent of total billed charges,50% of total billed charges,3.83,31.95,,2.288,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,2.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,2.864,percent of total billed charges,40% of total billed charges,3.83,10.2,
metroNIDAZOLE 500 mg/100 mL Sol [FMC],2561678,CDM,250,RC,J1836,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.03,136.6,,10.616,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,4.416,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.672,percent of total billed charges,35.15% of total billed charges,5.43,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,4.592,percent of total billed charges,31.95% of total billed charges,0.03,30.6,
metroNIDAZOLE 500 mg/100 mL Sol [FMC],2561678,CDM,250,RC,J1836,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.03,136.6,,2.504,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,3.72,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.672,percent of total billed charges,35.15% of total billed charges,1.92,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,4.592,percent of total billed charges,31.95% of total billed charges,0.03,30.6,
metroNIDAZOLE 500 mg/100 mL Sol [FMC],2561678,CDM,250,RC,J1836,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.03,136.6,,4.416,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.776,percent of total billed charges,35.15% of total billed charges,17.89,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,2.224,percent of total billed charges,31.95% of total billed charges,0.03,30.6,
metroNIDAZOLE 500 mg/100 mL Sol [FMC],2561678,CDM,250,RC,J1836,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.03,136.6,,4.808,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,3.256,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.776,percent of total billed charges,35.15% of total billed charges,17.89,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,2.224,percent of total billed charges,31.95% of total billed charges,0.03,30.6,
metroNIDAZOLE 500 mg/100 mL Sol [FMC],2561678,CDM,250,RC,J1836,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.03,136.6,,6.696,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,214.152,percent of total billed charges,35.15% of total billed charges,17.89,31.95,,214.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,268.112,percent of total billed charges,31.95% of total billed charges,0.03,30.6,
metroNIDAZOLE 500 mg/100 mL Sol [FMC],2561678,CDM,250,RC,J1836,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.03,136.6,,2.304,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,16.784,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,798.272,percent of total billed charges,35.15% of total billed charges,17.89,31.95,,798.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,999.4,percent of total billed charges,31.95% of total billed charges,0.03,30.6,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,15.952,percent of total billed charges,50% of total billed charges,0.96,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,99.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.896,percent of total billed charges,50% of total billed charges,0.96,31.95,,268.848,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,268.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,336.584,percent of total billed charges,40% of total billed charges,0.96,2.55,
metroNIDAZOLE 500 mg Tab (FMC),2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.048,percent of total billed charges,50% of total billed charges,0.96,31.95,,20.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,20.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,26,percent of total billed charges,40% of total billed charges,0.96,2.55,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3.19,1.914,,2.71,85,,2.168,Percent of total billed charges,85% of total billed charges,1.6,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.6,50,,2.584,percent of total billed charges,50% of total billed charges,1.02,31.95,,23.08,percent of total billed charges,31.95% of total billed charges,1.02,31.95,,23.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.21,38,,0.968,percent of total billed charges,38% of total billed charges,1.28,40,,28.896,percent of total billed charges,40% of total billed charges,1.02,2.71,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.656,percent of total billed charges,50% of total billed charges,0.96,31.95,,23.056,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,23.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,28.864,percent of total billed charges,40% of total billed charges,0.96,2.55,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.624,percent of total billed charges,50% of total billed charges,0.96,31.95,,8.472,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,8.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,10.608,percent of total billed charges,40% of total billed charges,0.96,2.55,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.072,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.24,percent of total billed charges,40% of total billed charges,0.96,2.55,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.136,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.424,percent of total billed charges,40% of total billed charges,0.96,2.55,
metroNIDAZOLE 500 mg Tab [FMC],2561686,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.936,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.488,percent of total billed charges,40% of total billed charges,0.96,2.55,
telmisartan 40 mg Tab [FMC],2561777,CDM,250,RC,,,OUTPATIENT,1,EA,18.8,11.28,,15.98,85,,12.784,Percent of total billed charges,85% of total billed charges,9.4,50,,6.208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.4,50,,3.064,percent of total billed charges,50% of total billed charges,6.01,31.95,,5.48,percent of total billed charges,31.95% of total billed charges,6.01,31.95,,5.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.14,38,,5.712,percent of total billed charges,38% of total billed charges,7.52,40,,6.864,percent of total billed charges,40% of total billed charges,6.01,15.98,
telmisartan 40 mg Tab [FMC],2561777,CDM,250,RC,,,OUTPATIENT,1,EA,17.94,10.764,,15.25,85,,12.2,Percent of total billed charges,85% of total billed charges,8.97,50,,10.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.97,50,,5.904,percent of total billed charges,50% of total billed charges,5.73,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,5.73,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.82,38,,5.456,percent of total billed charges,38% of total billed charges,7.18,40,,6.488,percent of total billed charges,40% of total billed charges,5.73,15.25,
telmisartan 40 mg Tab [FMC],2561777,CDM,250,RC,,,OUTPATIENT,1,EA,17.92,10.752,,15.23,85,,12.184,Percent of total billed charges,85% of total billed charges,8.96,50,,3.536,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.96,50,,1.2,percent of total billed charges,50% of total billed charges,5.73,31.95,,7.312,percent of total billed charges,31.95% of total billed charges,5.73,31.95,,7.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.81,38,,5.448,percent of total billed charges,38% of total billed charges,7.17,40,,9.16,percent of total billed charges,40% of total billed charges,5.73,15.23,
telmisartan 40 mg Tab [FMC],2561777,CDM,250,RC,,,OUTPATIENT,1,EA,17.85,10.71,,15.17,85,,12.136,Percent of total billed charges,85% of total billed charges,8.93,50,,4.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.93,50,,1.712,percent of total billed charges,50% of total billed charges,5.7,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,5.7,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.78,38,,5.424,percent of total billed charges,38% of total billed charges,7.14,40,,1.712,percent of total billed charges,40% of total billed charges,5.7,15.17,
midazolam 5 mg/mL preservative-free Inj 2 mL Soln [FMC],2561819,CDM,250,RC,J2250,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,0.26,136.6,,4.136,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.26,136.6,,1.688,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,1.488,percent of total billed charges,35.15% of total billed charges,17.89,31.95,,1.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,1.856,percent of total billed charges,31.95% of total billed charges,0.26,17.89,
midazolam 1 mg/mL Inj 2 mL Soln [FMC],2561827,CDM,250,RC,J2250,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,0.26,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.26,136.6,,1.624,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,1.44,percent of total billed charges,35.15% of total billed charges,319.5,31.95,,1.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,1.8,percent of total billed charges,31.95% of total billed charges,0.26,319.5,
midazolam 1 mg/mL Inj 2 mL Soln [FMC],2561827,CDM,250,RC,J2250,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,0.26,136.6,,4.52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.26,136.6,,1.688,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,2.888,percent of total billed charges,35.15% of total billed charges,319.5,31.95,,2.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.616,percent of total billed charges,31.95% of total billed charges,0.26,319.5,
midazolam 1 mg/mL Inj 2 mL Soln [FMC],2561827,CDM,250,RC,J2250,HCPCS,OUTPATIENT,2,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,0.26,136.6,,10.992,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.26,136.6,,1.648,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,345.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.26,345.06,
minoxidil 10 mg Tab [FMC],2561876,CDM,250,RC,,,OUTPATIENT,1,EA,6.88,4.128,,5.85,85,,4.68,Percent of total billed charges,85% of total billed charges,3.44,50,,10.992,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.44,50,,1.2,percent of total billed charges,50% of total billed charges,2.2,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,2.2,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.61,38,,2.088,percent of total billed charges,38% of total billed charges,2.75,40,,11.52,percent of total billed charges,40% of total billed charges,2.2,5.85,
pramipexole 0.25 mg Tab UD[FMC],2561918,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,182.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,11.52,percent of total billed charges,40% of total billed charges,0.96,2.55,
pramipexole 0.25 mg Tab UD[FMC],2561918,CDM,250,RC,,,OUTPATIENT,1,EA,10.86,6.516,,9.23,85,,7.384,Percent of total billed charges,85% of total billed charges,5.43,50,,182.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.43,50,,10.568,percent of total billed charges,50% of total billed charges,3.47,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,3.47,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.13,38,,3.304,percent of total billed charges,38% of total billed charges,4.34,40,,11.52,percent of total billed charges,40% of total billed charges,3.47,9.23,
pramipexole 0.25 mg Tab UD[FMC],2561918,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,15.456,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.576,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,11.52,percent of total billed charges,40% of total billed charges,0.96,2.55,
pramipexole 0.25 mg Tab UD[FMC],2561918,CDM,250,RC,,,OUTPATIENT,1,EA,9.55,5.73,,8.12,85,,6.496,Percent of total billed charges,85% of total billed charges,4.78,50,,2.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.78,50,,10.144,percent of total billed charges,50% of total billed charges,3.05,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,3.05,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.63,38,,2.904,percent of total billed charges,38% of total billed charges,3.82,40,,11.52,percent of total billed charges,40% of total billed charges,3.05,8.12,
pramipexole 0.25 mg Tab UD[FMC],2561918,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,11.52,percent of total billed charges,40% of total billed charges,0.96,2.55,
polyethylene glycol 3350 Oral Pwdr 17g packet Recon [FMC],2561926,CDM,250,RC,,,OUTPATIENT,1,EA,3.19,1.914,,2.71,85,,2.168,Percent of total billed charges,85% of total billed charges,1.6,50,,2.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.6,50,,1.224,percent of total billed charges,50% of total billed charges,1.02,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,1.02,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.21,38,,0.968,percent of total billed charges,38% of total billed charges,1.28,40,,11.52,percent of total billed charges,40% of total billed charges,1.02,2.71,
polyethylene glycol 3350 Oral Pwdr 17g packet Recon [FMC],2561926,CDM,250,RC,,,OUTPATIENT,1,EA,9.04,5.424,,7.68,85,,6.144,Percent of total billed charges,85% of total billed charges,4.52,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.52,50,,2.128,percent of total billed charges,50% of total billed charges,2.89,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,2.89,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.44,38,,2.752,percent of total billed charges,38% of total billed charges,3.62,40,,11.52,percent of total billed charges,40% of total billed charges,2.89,7.68,
polyethylene glycol 3350 Oral Pwdr 17g packet Recon [FMC],2561926,CDM,250,RC,,,OUTPATIENT,1,EA,6.07,3.642,,5.16,85,,4.128,Percent of total billed charges,85% of total billed charges,3.04,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.04,50,,1.208,percent of total billed charges,50% of total billed charges,1.94,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,1.94,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.31,38,,1.848,percent of total billed charges,38% of total billed charges,2.43,40,,1.048,percent of total billed charges,40% of total billed charges,1.94,5.16,
meloxicam 15 mg Tab [FMC],2561959,CDM,250,RC,,,OUTPATIENT,1,EA,15.57,9.342,,13.23,85,,10.584,Percent of total billed charges,85% of total billed charges,7.79,50,,35.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.79,50,,2.128,percent of total billed charges,50% of total billed charges,4.97,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,4.97,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.92,38,,4.736,percent of total billed charges,38% of total billed charges,6.23,40,,1.6,percent of total billed charges,40% of total billed charges,4.97,13.23,
meloxicam 15 mg Tab [FMC],2561959,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,28.536,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.224,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.312,percent of total billed charges,40% of total billed charges,0.96,2.55,
meloxicam 15 mg Tab [FMC],2561959,CDM,250,RC,,,OUTPATIENT,1,EA,15.74,9.444,,13.38,85,,10.704,Percent of total billed charges,85% of total billed charges,7.87,50,,48.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.87,50,,3.248,percent of total billed charges,50% of total billed charges,5.03,31.95,,1.992,percent of total billed charges,31.95% of total billed charges,5.03,31.95,,1.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.98,38,,4.784,percent of total billed charges,38% of total billed charges,6.3,40,,2.496,percent of total billed charges,40% of total billed charges,5.03,13.38,
meloxicam 15 mg Tab [FMC],2561959,CDM,250,RC,,,OUTPATIENT,1,EA,15.54,9.324,,13.21,85,,10.568,Percent of total billed charges,85% of total billed charges,7.77,50,,49.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.77,50,,2.472,percent of total billed charges,50% of total billed charges,4.97,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,4.97,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.91,38,,4.728,percent of total billed charges,38% of total billed charges,6.22,40,,1.744,percent of total billed charges,40% of total billed charges,4.97,13.21,
meloxicam 15 mg Tab [FMC],2561959,CDM,250,RC,,,OUTPATIENT,1,EA,15.74,9.444,,13.38,85,,10.704,Percent of total billed charges,85% of total billed charges,7.87,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.87,50,,2.472,percent of total billed charges,50% of total billed charges,5.03,31.95,,14.576,percent of total billed charges,31.95% of total billed charges,5.03,31.95,,14.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.98,38,,4.784,percent of total billed charges,38% of total billed charges,6.3,40,,18.256,percent of total billed charges,40% of total billed charges,5.03,13.38,
morphine 10 mg/mL preservative-free Inj Soln 1 mL [FMC],2561991,CDM,250,RC,J2270,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,6.49,136.6,,6.28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.49,136.6,,2.224,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,14.536,percent of total billed charges,35.15% of total billed charges,345.38,31.95,,14.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,18.2,percent of total billed charges,31.95% of total billed charges,4.47,345.38,
morphine 10 mg/mL preservative-free Inj Soln 1 mL [FMC],2561991,CDM,250,RC,J2270,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,6.49,136.6,,6.28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.49,136.6,,2.536,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,14.536,percent of total billed charges,35.15% of total billed charges,348.26,31.95,,14.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,18.2,percent of total billed charges,31.95% of total billed charges,4.47,348.26,
morphine 1 mg/mL preservative-free 30ml Sol [FMC],2562015,CDM,250,RC,,,OUTPATIENT,30,ML,31.12,18.672,,26.45,85,,21.16,Percent of total billed charges,85% of total billed charges,15.56,50,,2.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.56,50,,2.4,percent of total billed charges,50% of total billed charges,9.94,31.95,,10.904,percent of total billed charges,31.95% of total billed charges,9.94,31.95,,10.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.83,38,,9.464,percent of total billed charges,38% of total billed charges,12.45,40,,13.648,percent of total billed charges,40% of total billed charges,9.94,26.45,
morphine 1 mg/mL preservative-free 30ml Sol [FMC],2562015,CDM,250,RC,,,OUTPATIENT,30,ML,18.2,10.92,,15.47,85,,12.376,Percent of total billed charges,85% of total billed charges,9.1,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.1,50,,2.4,percent of total billed charges,50% of total billed charges,5.81,31.95,,13.952,percent of total billed charges,31.95% of total billed charges,5.81,31.95,,13.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.92,38,,5.536,percent of total billed charges,38% of total billed charges,7.28,40,,17.472,percent of total billed charges,40% of total billed charges,5.81,15.47,
ibuprofen 100 mg/5 mL Susp UD 5mL [FMC],2562031,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.488,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,14.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,14.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,18.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 100 mg/5 mL Susp UD 5mL [FMC],2562031,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.488,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,14.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,14.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,18.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 100 mg/5 mL Susp UD 5mL [FMC],2562031,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,86.44,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,86.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,108.224,percent of total billed charges,40% of total billed charges,0.96,2.55,
ibuprofen 100 mg/5 mL Susp UD 5mL [FMC],2562031,CDM,250,RC,,,OUTPATIENT,5,ML,3.04,1.824,,2.58,85,,2.064,Percent of total billed charges,85% of total billed charges,1.52,50,,1.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.52,50,,1.2,percent of total billed charges,50% of total billed charges,0.97,31.95,,85.48,percent of total billed charges,31.95% of total billed charges,0.97,31.95,,85.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.16,38,,0.928,percent of total billed charges,38% of total billed charges,1.22,40,,107.016,percent of total billed charges,40% of total billed charges,0.97,2.58,
ibuprofen 100 mg/5 mL Susp UD 5mL [FMC],2562031,CDM,250,RC,,,OUTPATIENT,5,ML,6.15,3.69,,5.23,85,,4.184,Percent of total billed charges,85% of total billed charges,3.08,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.08,50,,1.2,percent of total billed charges,50% of total billed charges,1.96,31.95,,86.44,percent of total billed charges,31.95% of total billed charges,1.96,31.95,,86.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.34,38,,1.872,percent of total billed charges,38% of total billed charges,2.46,40,,108.224,percent of total billed charges,40% of total billed charges,1.96,5.23,
ibuprofen 100 mg/5 mL Susp UD 5mL [FMC],2562031,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
Multiple Vitamins IV Sol 10 mL [FMC],2562114,CDM,250,RC,,,OUTPATIENT,10,ML,859.95,515.97,,730.96,85,,584.768,Percent of total billed charges,85% of total billed charges,429.98,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,429.98,50,,1.2,percent of total billed charges,50% of total billed charges,274.75,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,274.75,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,326.78,38,,261.424,percent of total billed charges,38% of total billed charges,343.98,40,,0.96,percent of total billed charges,40% of total billed charges,274.75,730.96,
Multiple Vitamins IV Sol 10 mL [FMC],2562114,CDM,250,RC,,,OUTPATIENT,10,ML,29.58,17.748,,25.14,85,,20.112,Percent of total billed charges,85% of total billed charges,14.79,50,,11.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.79,50,,1.2,percent of total billed charges,50% of total billed charges,9.45,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,9.45,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.24,38,,8.992,percent of total billed charges,38% of total billed charges,11.83,40,,0.96,percent of total billed charges,40% of total billed charges,9.45,25.14,
Multiple Vitamins IV Sol 10 mL [FMC],2562114,CDM,250,RC,,,OUTPATIENT,10,ML,39.45,23.67,,33.53,85,,26.824,Percent of total billed charges,85% of total billed charges,19.73,50,,19.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.73,50,,1.2,percent of total billed charges,50% of total billed charges,12.6,31.95,,2.776,percent of total billed charges,31.95% of total billed charges,12.6,31.95,,2.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.99,38,,11.992,percent of total billed charges,38% of total billed charges,15.78,40,,3.48,percent of total billed charges,40% of total billed charges,12.6,33.53,
nabumetone 500 mg Tab [FMC],2562213,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,18.032,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.968,percent of total billed charges,40% of total billed charges,0.96,2.55,
nabumetone 500 mg Tab [FMC],2562213,CDM,250,RC,,,OUTPATIENT,1,EA,3.82,2.292,,3.25,85,,2.6,Percent of total billed charges,85% of total billed charges,1.91,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.91,50,,4.8,percent of total billed charges,50% of total billed charges,1.22,31.95,,180.392,percent of total billed charges,31.95% of total billed charges,1.22,31.95,,180.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.45,38,,1.16,percent of total billed charges,38% of total billed charges,1.53,40,,225.848,percent of total billed charges,40% of total billed charges,1.22,3.25,
nabumetone 500 mg Tab [FMC],2562213,CDM,250,RC,,,OUTPATIENT,1,EA,4.34,2.604,,3.69,85,,2.952,Percent of total billed charges,85% of total billed charges,2.17,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.17,50,,8.896,percent of total billed charges,50% of total billed charges,1.39,31.95,,152.592,percent of total billed charges,31.95% of total billed charges,1.39,31.95,,152.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.65,38,,1.32,percent of total billed charges,38% of total billed charges,1.74,40,,191.04,percent of total billed charges,40% of total billed charges,1.39,3.69,
nabumetone 500 mg Tab [FMC],2562213,CDM,250,RC,,,OUTPATIENT,1,EA,4.02,2.412,,3.42,85,,2.736,Percent of total billed charges,85% of total billed charges,2.01,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.01,50,,4.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,213.072,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,213.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.53,38,,1.224,percent of total billed charges,38% of total billed charges,1.61,40,,266.76,percent of total billed charges,40% of total billed charges,1.28,3.42,
sodium chloride 1 g Tab [FMC],2562247,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.464,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.352,percent of total billed charges,40% of total billed charges,0.96,2.55,
sodium chloride 1 g Tab [FMC],2562247,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.92,percent of total billed charges,50% of total billed charges,0.96,31.95,,25.96,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,25.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,32.496,percent of total billed charges,40% of total billed charges,0.96,2.55,
sodium chloride 1 g Tab [FMC],2562247,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,236.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.92,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.264,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.832,percent of total billed charges,40% of total billed charges,0.96,2.55,
nalbuphine 10 mg/mL Inj Sol [FMC],2562304,CDM,250,RC,J2300,HCPCS,OUTPATIENT,1,ML,14.34,8.604,,12.19,85,,9.752,Percent of total billed charges,85% of total billed charges,4.32,136.6,,213.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.32,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,5.04,35.15,,2.44,percent of total billed charges,35.15% of total billed charges,348.26,31.95,,2.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.45,38,,4.36,percent of total billed charges,38% of total billed charges,4.58,31.95,,3.056,percent of total billed charges,31.95% of total billed charges,4.32,348.26,
naloxone 0.4 mg/mL Inj Sol [FMC],2562346,CDM,250,RC,J2310,HCPCS,OUTPATIENT,1,ML,61.74,37.044,,52.48,85,,41.984,Percent of total billed charges,85% of total billed charges,14.33,136.6,,212.864,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.33,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,21.7,35.15,,2.312,fee schedule,35.15% of LA custom fee schedule,19.73,31.95,,2.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,23.46,38,,18.768,percent of total billed charges,38% of total billed charges,19.73,31.95,,2.896,Fee Schedule,31.95% of LA custom fee schedule,14.33,52.48,
naloxone 0.4 mg/mL Inj Sol [FMC],2562346,CDM,250,RC,J2310,HCPCS,OUTPATIENT,1,ML,77.1,46.26,,65.54,85,,52.432,Percent of total billed charges,85% of total billed charges,14.33,136.6,,213.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.33,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,27.1,35.15,,0.968,fee schedule,35.15% of LA custom fee schedule,24.63,31.95,,0.968,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.3,38,,23.44,percent of total billed charges,38% of total billed charges,24.63,31.95,,1.216,Fee Schedule,31.95% of LA custom fee schedule,14.33,65.54,
naloxone 0.4 mg/mL Inj Sol [FMC],2562346,CDM,250,RC,J2310,HCPCS,OUTPATIENT,1,ML,77.1,46.26,,65.54,85,,52.432,Percent of total billed charges,85% of total billed charges,14.33,136.6,,8.28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.33,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,27.1,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,24.63,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.3,38,,23.44,percent of total billed charges,38% of total billed charges,24.63,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,14.33,65.54,
naloxone 0.4 mg/mL Inj Sol [FMC],2562346,CDM,250,RC,J2310,HCPCS,OUTPATIENT,1,ML,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,14.33,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.33,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,1.248,fee schedule,35.15% of LA custom fee schedule,7.48,31.95,,1.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,1.56,Fee Schedule,31.95% of LA custom fee schedule,7.48,19.89,
naproxen 375 mg Tab [FMC],2562379,CDM,250,RC,,,OUTPATIENT,1,EA,3.46,2.076,,2.94,85,,2.352,Percent of total billed charges,85% of total billed charges,1.73,50,,10.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.73,50,,4.912,percent of total billed charges,50% of total billed charges,1.11,31.95,,1.248,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,1.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,1.56,percent of total billed charges,40% of total billed charges,1.11,2.94,
naproxen 375 mg Tab [FMC],2562379,CDM,250,RC,,,OUTPATIENT,1,EA,3.45,2.07,,2.93,85,,2.344,Percent of total billed charges,85% of total billed charges,1.73,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.73,50,,2.4,percent of total billed charges,50% of total billed charges,1.1,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,1.1,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,1.424,percent of total billed charges,40% of total billed charges,1.1,2.93,
naproxen 375 mg Tab [FMC],2562379,CDM,250,RC,,,OUTPATIENT,1,EA,3.21,1.926,,2.73,85,,2.184,Percent of total billed charges,85% of total billed charges,1.61,50,,1.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.61,50,,2.4,percent of total billed charges,50% of total billed charges,1.03,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,1.03,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.22,38,,0.976,percent of total billed charges,38% of total billed charges,1.28,40,,1.424,percent of total billed charges,40% of total billed charges,1.03,2.73,
naproxen 375 mg Tab [FMC],2562379,CDM,250,RC,,,OUTPATIENT,1,EA,3.46,2.076,,2.94,85,,2.352,Percent of total billed charges,85% of total billed charges,1.73,50,,3.544,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.73,50,,1.488,percent of total billed charges,50% of total billed charges,1.11,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,1.28,percent of total billed charges,40% of total billed charges,1.11,2.94,
naproxen 500 mg Tab [FMC],2562387,CDM,250,RC,,,OUTPATIENT,1,EA,4.36,2.616,,3.71,85,,2.968,Percent of total billed charges,85% of total billed charges,2.18,50,,1.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.18,50,,1.2,percent of total billed charges,50% of total billed charges,1.39,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,1.39,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.66,38,,1.328,percent of total billed charges,38% of total billed charges,1.74,40,,1.424,percent of total billed charges,40% of total billed charges,1.39,3.71,
naproxen 500 mg Tab [FMC],2562387,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.424,percent of total billed charges,40% of total billed charges,0.96,2.55,
naproxen 500 mg Tab [FMC],2562387,CDM,250,RC,,,OUTPATIENT,1,EA,4.36,2.616,,3.71,85,,2.968,Percent of total billed charges,85% of total billed charges,2.18,50,,1.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.18,50,,1.2,percent of total billed charges,50% of total billed charges,1.39,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.39,31.95,,308,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.66,38,,1.328,percent of total billed charges,38% of total billed charges,1.74,40,,9.2,percent of total billed charges,40% of total billed charges,1.39,3.71,
cromolyn Nasal 5.2 mg/inh Spry [FMC],2562460,CDM,250,RC,,,OUTPATIENT,26,UN,41.92,25.152,,35.63,85,,28.504,Percent of total billed charges,85% of total billed charges,20.96,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.96,50,,1.648,percent of total billed charges,50% of total billed charges,13.39,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,13.39,31.95,,311.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.93,38,,12.744,percent of total billed charges,38% of total billed charges,16.77,40,,9.2,percent of total billed charges,40% of total billed charges,13.39,35.63,
bacitracin/neomycin/polymyxin B ophthalmic 400 units-3.5 mg-10000 units per gm Oint [FMC],2562510,CDM,250,RC,,,OUTPATIENT,3.5,EA,179.56,107.736,,152.63,85,,122.104,Percent of total billed charges,85% of total billed charges,89.78,50,,36.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,89.78,50,,1.2,percent of total billed charges,50% of total billed charges,57.37,31.95,,4.384,percent of total billed charges,31.95% of total billed charges,57.37,31.95,,316.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.23,38,,54.584,percent of total billed charges,38% of total billed charges,71.82,40,,3.984,percent of total billed charges,40% of total billed charges,57.37,152.63,
bacitracin/neomycin/polymyxin B ophthalmic 400 units-3.5 mg-10000 units per gm Oint [FMC],2562510,CDM,250,RC,,,OUTPATIENT,3.5,EA,185.09,111.054,,157.33,85,,125.864,Percent of total billed charges,85% of total billed charges,92.55,50,,63.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,92.55,50,,1.2,percent of total billed charges,50% of total billed charges,59.14,31.95,,3.92,percent of total billed charges,31.95% of total billed charges,59.14,31.95,,318.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.33,38,,56.264,percent of total billed charges,38% of total billed charges,74.04,40,,3.568,percent of total billed charges,40% of total billed charges,59.14,157.33,
bacitracin/neomycin/polymyxin B ophthalmic 400 units-3.5 mg-10000 units per gm Oint [FMC],2562510,CDM,250,RC,,,OUTPATIENT,3.5,EA,170.76,102.456,,145.15,85,,116.12,Percent of total billed charges,85% of total billed charges,85.38,50,,34.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85.38,50,,1.2,percent of total billed charges,50% of total billed charges,54.56,31.95,,3.512,percent of total billed charges,31.95% of total billed charges,54.56,31.95,,328.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.89,38,,51.912,percent of total billed charges,38% of total billed charges,68.3,40,,3.192,percent of total billed charges,40% of total billed charges,54.56,145.15,
bacitracin/neomycin/polymyxin B ophthalmic 400 units-3.5 mg-10000 units per gm Oint [FMC],2562510,CDM,250,RC,,,OUTPATIENT,3.5,EA,185.09,111.054,,157.33,85,,125.864,Percent of total billed charges,85% of total billed charges,92.55,50,,35.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,92.55,50,,2.104,percent of total billed charges,50% of total billed charges,59.14,31.95,,14.704,percent of total billed charges,31.95% of total billed charges,59.14,31.95,,14.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.33,38,,56.264,percent of total billed charges,38% of total billed charges,74.04,40,,18.416,percent of total billed charges,40% of total billed charges,59.14,157.33,
dexamethasone/neomycin/polymyxin B Ophth Susp [FMC],2562528,CDM,250,RC,,,OUTPATIENT,5,EA,64.55,38.73,,54.87,85,,43.896,Percent of total billed charges,85% of total billed charges,32.28,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.28,50,,1.2,percent of total billed charges,50% of total billed charges,20.62,31.95,,14.704,percent of total billed charges,31.95% of total billed charges,20.62,31.95,,14.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.53,38,,19.624,percent of total billed charges,38% of total billed charges,25.82,40,,18.416,percent of total billed charges,40% of total billed charges,20.62,54.87,
dexamethasone/neomycin/polymyxin B Ophth Susp [FMC],2562528,CDM,250,RC,,,OUTPATIENT,5,EA,143,85.8,,121.55,85,,97.24,Percent of total billed charges,85% of total billed charges,71.5,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,71.5,50,,1.448,percent of total billed charges,50% of total billed charges,45.69,31.95,,0.776,percent of total billed charges,31.95% of total billed charges,45.69,31.95,,0.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.34,38,,43.472,percent of total billed charges,38% of total billed charges,57.2,40,,0.976,percent of total billed charges,40% of total billed charges,45.69,121.55,
neostigmine 1 mg/mL Sol [FMC],2562569,CDM,250,RC,J2710,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,2.65,136.6,,6.504,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.65,136.6,,1.448,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.32,percent of total billed charges,35.15% of total billed charges,363.91,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,4.16,percent of total billed charges,31.95% of total billed charges,2.65,363.91,
neostigmine 1 mg/mL Sol [FMC],2562569,CDM,250,RC,J2710,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,2.65,136.6,,23.072,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.65,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,2.992,percent of total billed charges,35.15% of total billed charges,373.5,31.95,,2.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.744,percent of total billed charges,31.95% of total billed charges,2.65,373.5,
neostigmine 1 mg/mL Sol [FMC],2562569,CDM,250,RC,J2710,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,2.65,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.65,136.6,,7.16,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.32,percent of total billed charges,35.15% of total billed charges,373.5,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,4.16,percent of total billed charges,31.95% of total billed charges,2.65,373.5,
neostigmine 1 mg/mL Sol [FMC],2562569,CDM,250,RC,J2710,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,2.65,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.65,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.88,percent of total billed charges,35.15% of total billed charges,373.82,31.95,,0.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.104,percent of total billed charges,31.95% of total billed charges,2.65,373.82,
phenylephrine nasal 1% spray [FMC],2562577,CDM,250,RC,,,OUTPATIENT,15,UN,13.88,8.328,,11.8,85,,9.44,Percent of total billed charges,85% of total billed charges,6.94,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.94,50,,1.2,percent of total billed charges,50% of total billed charges,4.43,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,4.43,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.27,38,,4.216,percent of total billed charges,38% of total billed charges,5.55,40,,1.008,percent of total billed charges,40% of total billed charges,4.43,11.8,
phenylephrine nasal 1% spray [FMC],2562577,CDM,250,RC,,,OUTPATIENT,15,UN,7.62,4.572,,6.48,85,,5.184,Percent of total billed charges,85% of total billed charges,3.81,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.81,50,,1.2,percent of total billed charges,50% of total billed charges,2.43,31.95,,4.448,percent of total billed charges,31.95% of total billed charges,2.43,31.95,,4.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.9,38,,2.32,percent of total billed charges,38% of total billed charges,3.05,40,,5.568,percent of total billed charges,40% of total billed charges,2.43,6.48,
gabapentin 100 mg Cap [FMC],2562668,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.352,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.448,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.568,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 100 mg Cap [FMC],2562668,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.76,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,338.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 100 mg Cap [FMC] - - Inpatient - FMC HOSP - Active - 68084-0783-01,2562668,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.032,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,347.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 100 mg Cap,2562668,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,14.704,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,14.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,18.416,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin  100 mg Cap [FMC],2562668,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,537.336,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,347.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,488.424,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin  100 mg Cap [FMC],2562668,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,460.384,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,356.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,418.472,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,130.888,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,4.39,2.634,,3.73,85,,2.984,Percent of total billed charges,85% of total billed charges,2.2,50,,40.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.2,50,,14.624,percent of total billed charges,50% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.67,38,,1.336,percent of total billed charges,38% of total billed charges,1.76,40,,0.96,percent of total billed charges,40% of total billed charges,1.4,3.73,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,32.664,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 300mg cap {FMC},2562676,CDM,250,RC,,,OUTPATIENT,1,EA,5.4,3.24,,4.59,85,,3.672,Percent of total billed charges,85% of total billed charges,2.7,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.7,50,,40.304,percent of total billed charges,50% of total billed charges,1.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.05,38,,1.64,percent of total billed charges,38% of total billed charges,2.16,40,,0.96,percent of total billed charges,40% of total billed charges,1.73,4.59,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,4.47,2.682,,3.8,85,,3.04,Percent of total billed charges,85% of total billed charges,2.24,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.24,50,,23.152,percent of total billed charges,50% of total billed charges,1.43,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,1.43,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.7,38,,1.36,percent of total billed charges,38% of total billed charges,1.79,40,,1.744,percent of total billed charges,40% of total billed charges,1.43,3.8,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,234,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.448,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.816,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,4.35,2.61,,3.7,85,,2.96,Percent of total billed charges,85% of total billed charges,2.18,50,,5.856,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.18,50,,20.44,percent of total billed charges,50% of total billed charges,1.39,31.95,,0.856,percent of total billed charges,31.95% of total billed charges,1.39,31.95,,0.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.65,38,,1.32,percent of total billed charges,38% of total billed charges,1.74,40,,1.072,percent of total billed charges,40% of total billed charges,1.39,3.7,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.896,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,33.992,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.432,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.792,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,4.32,2.592,,3.67,85,,2.936,Percent of total billed charges,85% of total billed charges,2.16,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.16,50,,1.2,percent of total billed charges,50% of total billed charges,1.38,31.95,,53.704,percent of total billed charges,31.95% of total billed charges,1.38,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.64,38,,1.312,percent of total billed charges,38% of total billed charges,1.73,40,,48.808,percent of total billed charges,40% of total billed charges,1.38,3.67,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,4.32,2.592,,3.67,85,,2.936,Percent of total billed charges,85% of total billed charges,2.16,50,,7.016,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.16,50,,1.2,percent of total billed charges,50% of total billed charges,1.38,31.95,,46.904,percent of total billed charges,31.95% of total billed charges,1.38,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.64,38,,1.312,percent of total billed charges,38% of total billed charges,1.73,40,,42.632,percent of total billed charges,40% of total billed charges,1.38,3.67,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,4.47,2.682,,3.8,85,,3.04,Percent of total billed charges,85% of total billed charges,2.24,50,,6.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.24,50,,1.2,percent of total billed charges,50% of total billed charges,1.43,31.95,,36.552,percent of total billed charges,31.95% of total billed charges,1.43,31.95,,36.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.7,38,,1.36,percent of total billed charges,38% of total billed charges,1.79,40,,45.76,percent of total billed charges,40% of total billed charges,1.43,3.8,
gabapentin 300 mg Cap [FMC],2562676,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,11.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,18.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.336,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,13.992,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.392,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.656,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.088,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,3.97,2.382,,3.37,85,,2.696,Percent of total billed charges,85% of total billed charges,1.99,50,,19.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.99,50,,3.016,percent of total billed charges,50% of total billed charges,1.27,31.95,,3.624,percent of total billed charges,31.95% of total billed charges,1.27,31.95,,3.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.51,38,,1.208,percent of total billed charges,38% of total billed charges,1.59,40,,4.536,percent of total billed charges,40% of total billed charges,1.27,3.37,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,6.48,3.888,,5.51,85,,4.408,Percent of total billed charges,85% of total billed charges,3.24,50,,24.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.24,50,,1.744,percent of total billed charges,50% of total billed charges,2.07,31.95,,5.784,percent of total billed charges,31.95% of total billed charges,2.07,31.95,,5.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.46,38,,1.968,percent of total billed charges,38% of total billed charges,2.59,40,,7.24,percent of total billed charges,40% of total billed charges,2.07,5.51,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.776,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.232,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.512,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.896,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.512,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.896,percent of total billed charges,40% of total billed charges,0.96,2.55,
gabapentin 400 mg Cap [FMC],2562684,CDM,250,RC,,,OUTPATIENT,1,EA,5.19,3.114,,4.41,85,,3.528,Percent of total billed charges,85% of total billed charges,2.6,50,,1.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.6,50,,1.2,percent of total billed charges,50% of total billed charges,1.66,31.95,,1.512,percent of total billed charges,31.95% of total billed charges,1.66,31.95,,1.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.97,38,,1.576,percent of total billed charges,38% of total billed charges,2.08,40,,1.896,percent of total billed charges,40% of total billed charges,1.66,4.41,
niCARdipine 20 mg Cap [FMC],2562791,CDM,250,RC,,,OUTPATIENT,1,EA,7.24,4.344,,6.15,85,,4.92,Percent of total billed charges,85% of total billed charges,3.62,50,,2.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.62,50,,84.44,percent of total billed charges,50% of total billed charges,2.31,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.31,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.75,38,,2.2,percent of total billed charges,38% of total billed charges,2.9,40,,0.96,percent of total billed charges,40% of total billed charges,2.31,6.15,
nicotine 14 mg/24 hr ER [FMC],2562817,CDM,250,RC,,,OUTPATIENT,1,EA,6.93,4.158,,5.89,85,,4.712,Percent of total billed charges,85% of total billed charges,3.47,50,,26.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,82.672,percent of total billed charges,50% of total billed charges,2.21,31.95,,1.248,percent of total billed charges,31.95% of total billed charges,2.21,31.95,,1.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.63,38,,2.104,percent of total billed charges,38% of total billed charges,2.77,40,,1.56,percent of total billed charges,40% of total billed charges,2.21,5.89,
nicotine 14 mg/24 hr ER [FMC],2562817,CDM,250,RC,,,OUTPATIENT,1,EA,6.93,4.158,,5.89,85,,4.712,Percent of total billed charges,85% of total billed charges,3.47,50,,26.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,19.656,percent of total billed charges,50% of total billed charges,2.21,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.21,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.63,38,,2.104,percent of total billed charges,38% of total billed charges,2.77,40,,0.96,percent of total billed charges,40% of total billed charges,2.21,5.89,
NICOTINE TD AP 21MG/24HR 14 [FMC],2562825,CDM,250,RC,,,OUTPATIENT,1,EA,6.96,4.176,,5.92,85,,4.736,Percent of total billed charges,85% of total billed charges,3.48,50,,26.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.48,50,,20.152,percent of total billed charges,50% of total billed charges,2.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.64,38,,2.112,percent of total billed charges,38% of total billed charges,2.78,40,,0.96,percent of total billed charges,40% of total billed charges,2.22,5.92,
NICOTINE TD AP 21MG/24HR 14 [FMC],2562825,CDM,250,RC,,,OUTPATIENT,1,EA,8.19,4.914,,6.96,85,,5.568,Percent of total billed charges,85% of total billed charges,4.1,50,,26.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.1,50,,20.912,percent of total billed charges,50% of total billed charges,2.62,31.95,,15.456,percent of total billed charges,31.95% of total billed charges,2.62,31.95,,15.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.11,38,,2.488,percent of total billed charges,38% of total billed charges,3.28,40,,19.344,percent of total billed charges,40% of total billed charges,2.62,6.96,
NICOTINE TD AP 21MG/24HR 14 [FMC],2562825,CDM,250,RC,,,OUTPATIENT,1,EA,6.93,4.158,,5.89,85,,4.712,Percent of total billed charges,85% of total billed charges,3.47,50,,26.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,2.16,percent of total billed charges,50% of total billed charges,2.21,31.95,,3.984,percent of total billed charges,31.95% of total billed charges,2.21,31.95,,3.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.63,38,,2.104,percent of total billed charges,38% of total billed charges,2.77,40,,4.992,percent of total billed charges,40% of total billed charges,2.21,5.89,
NICOTINE TD AP 21MG/24HR 14 [FMC],2562825,CDM,250,RC,,,OUTPATIENT,1,EA,11.71,7.026,,9.95,85,,7.96,Percent of total billed charges,85% of total billed charges,5.86,50,,26.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.86,50,,2.68,percent of total billed charges,50% of total billed charges,3.74,31.95,,12.64,percent of total billed charges,31.95% of total billed charges,3.74,31.95,,12.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.45,38,,3.56,percent of total billed charges,38% of total billed charges,4.68,40,,15.824,percent of total billed charges,40% of total billed charges,3.74,9.95,
NIFEdipine 10 mg Cap [FMC],2562841,CDM,250,RC,,,OUTPATIENT,1,EA,4.18,2.508,,3.55,85,,2.84,Percent of total billed charges,85% of total billed charges,2.09,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.09,50,,2.16,percent of total billed charges,50% of total billed charges,1.34,31.95,,14.048,percent of total billed charges,31.95% of total billed charges,1.34,31.95,,14.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.59,38,,1.272,percent of total billed charges,38% of total billed charges,1.67,40,,17.584,percent of total billed charges,40% of total billed charges,1.34,3.55,
NIFEdipine 10 mg Cap [FMC],2562841,CDM,250,RC,,,OUTPATIENT,1,EA,6.38,3.828,,5.42,85,,4.336,Percent of total billed charges,85% of total billed charges,3.19,50,,8.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.19,50,,1.2,percent of total billed charges,50% of total billed charges,2.04,31.95,,6.984,percent of total billed charges,31.95% of total billed charges,2.04,31.95,,6.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.42,38,,1.936,percent of total billed charges,38% of total billed charges,2.55,40,,8.736,percent of total billed charges,40% of total billed charges,2.04,5.42,
NIFEdipine 10 mg Cap [FMC],2562841,CDM,250,RC,,,OUTPATIENT,1,EA,4.07,2.442,,3.46,85,,2.768,Percent of total billed charges,85% of total billed charges,2.04,50,,10.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.04,50,,1.2,percent of total billed charges,50% of total billed charges,1.3,31.95,,8.032,percent of total billed charges,31.95% of total billed charges,1.3,31.95,,8.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.55,38,,1.24,percent of total billed charges,38% of total billed charges,1.63,40,,10.048,percent of total billed charges,40% of total billed charges,1.3,3.46,
NIFEdipine 10 mg Cap [FMC],2562841,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.464,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,18.952,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,18.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,23.728,percent of total billed charges,40% of total billed charges,0.96,2.55,
NIFEdipine 30 mg ER Tab [FMC],2562866,CDM,250,RC,,,OUTPATIENT,1,EA,4.3,2.58,,3.66,85,,2.928,Percent of total billed charges,85% of total billed charges,2.15,50,,21.872,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.15,50,,1.2,percent of total billed charges,50% of total billed charges,1.37,31.95,,12.328,percent of total billed charges,31.95% of total billed charges,1.37,31.95,,12.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.63,38,,1.304,percent of total billed charges,38% of total billed charges,1.72,40,,15.432,percent of total billed charges,40% of total billed charges,1.37,3.66,
NIFEdipine 30 mg ER Tab [FMC],2562866,CDM,250,RC,,,OUTPATIENT,1,EA,4.3,2.58,,3.66,85,,2.928,Percent of total billed charges,85% of total billed charges,2.15,50,,24.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.15,50,,1.2,percent of total billed charges,50% of total billed charges,1.37,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.37,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.63,38,,1.304,percent of total billed charges,38% of total billed charges,1.72,40,,9.2,percent of total billed charges,40% of total billed charges,1.37,3.66,
NIFEdipine 30 mg ER Tab [FMC],2562866,CDM,250,RC,,,OUTPATIENT,1,EA,4.38,2.628,,3.72,85,,2.976,Percent of total billed charges,85% of total billed charges,2.19,50,,4.872,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.19,50,,19.568,percent of total billed charges,50% of total billed charges,1.4,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.4,31.95,,362.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.66,38,,1.328,percent of total billed charges,38% of total billed charges,1.75,40,,9.2,percent of total billed charges,40% of total billed charges,1.4,3.72,
nitroglycerin 0.4 mg/hr Transderm ER Film [FMC],2562940,CDM,250,RC,,,OUTPATIENT,1,EA,6.1,3.66,,5.19,85,,4.152,Percent of total billed charges,85% of total billed charges,3.05,50,,4.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.05,50,,72.344,percent of total billed charges,50% of total billed charges,1.95,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.95,31.95,,365,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.32,38,,1.856,percent of total billed charges,38% of total billed charges,2.44,40,,9.2,percent of total billed charges,40% of total billed charges,1.95,5.19,
nitroglycerin 0.4 mg/hr Transderm ER Film [FMC],2562940,CDM,250,RC,,,OUTPATIENT,1,EA,6.08,3.648,,5.17,85,,4.136,Percent of total billed charges,85% of total billed charges,3.04,50,,4.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.04,50,,75.08,percent of total billed charges,50% of total billed charges,1.94,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.94,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.31,38,,1.848,percent of total billed charges,38% of total billed charges,2.43,40,,0.96,percent of total billed charges,40% of total billed charges,1.94,5.17,
nitroglycerin 0.4 mg/hr Transderm ER Film [FMC],2562940,CDM,250,RC,,,OUTPATIENT,1,EA,7.06,4.236,,6,85,,4.8,Percent of total billed charges,85% of total billed charges,3.53,50,,13.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.53,50,,79.304,percent of total billed charges,50% of total billed charges,2.26,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.26,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.68,38,,2.144,percent of total billed charges,38% of total billed charges,2.82,40,,0.968,percent of total billed charges,40% of total billed charges,2.26,6,
Epinephrine/Lidocaine/Tetracaine topical 0.18%-4%-0.5% Gel [FMC],2562948,CDM,250,RC,,,OUTPATIENT,3,ML,146.25,87.75,,124.31,85,,99.448,Percent of total billed charges,85% of total billed charges,73.13,50,,13.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.13,50,,2.96,percent of total billed charges,50% of total billed charges,46.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,46.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.58,38,,44.464,percent of total billed charges,38% of total billed charges,58.5,40,,0.96,percent of total billed charges,40% of total billed charges,46.73,124.31,
Epinephrine/Lidocaine/Tetracaine topical 0.18%-4%-0.5% Gel [FMC],2562948,CDM,250,RC,,,OUTPATIENT,3,ML,52,31.2,,44.2,85,,35.36,Percent of total billed charges,85% of total billed charges,26,50,,17.536,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26,50,,1.552,percent of total billed charges,50% of total billed charges,16.61,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,16.61,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.76,38,,15.808,percent of total billed charges,38% of total billed charges,20.8,40,,0.96,percent of total billed charges,40% of total billed charges,16.61,44.2,
nitroglycerin 0.4 mg SubL Spry [FMC],2562957,CDM,250,RC,,,OUTPATIENT,4.9,UN,729.53,437.718,,620.1,85,,496.08,Percent of total billed charges,85% of total billed charges,364.77,50,,9.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,364.77,50,,1.2,percent of total billed charges,50% of total billed charges,233.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,233.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,277.22,38,,221.776,percent of total billed charges,38% of total billed charges,291.81,40,,0.96,percent of total billed charges,40% of total billed charges,233.08,620.1,
nitroglycerin 0.4 mg SubL Spry [FMC],2562957,CDM,250,RC,,,OUTPATIENT,4.9,UN,661.71,397.026,,562.45,85,,449.96,Percent of total billed charges,85% of total billed charges,330.86,50,,8.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,330.86,50,,1.2,percent of total billed charges,50% of total billed charges,211.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,211.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,251.45,38,,201.16,percent of total billed charges,38% of total billed charges,264.68,40,,0.96,percent of total billed charges,40% of total billed charges,211.42,562.45,
nitroglycerin 0.4 mg SubL Spry [FMC],2562957,CDM,250,RC,,,OUTPATIENT,4.9,UN,661.71,397.026,,562.45,85,,449.96,Percent of total billed charges,85% of total billed charges,330.86,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,330.86,50,,1.56,percent of total billed charges,50% of total billed charges,211.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,211.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,251.45,38,,201.16,percent of total billed charges,38% of total billed charges,264.68,40,,0.96,percent of total billed charges,40% of total billed charges,211.42,562.45,
nitroglycerin 0.4 mg SubL Spry [FMC],2562957,CDM,250,RC,,,OUTPATIENT,4.9,UN,729.53,437.718,,620.1,85,,496.08,Percent of total billed charges,85% of total billed charges,364.77,50,,5.728,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,364.77,50,,1.304,percent of total billed charges,50% of total billed charges,233.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,233.08,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,277.22,38,,221.776,percent of total billed charges,38% of total billed charges,291.81,40,,0.96,percent of total billed charges,40% of total billed charges,233.08,620.1,
nitroglycerin 0.4 mg sublingual Tab [FMC],2562965,CDM,250,RC,,,OUTPATIENT,1,EA,5.35,3.21,,4.55,85,,3.64,Percent of total billed charges,85% of total billed charges,2.68,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.68,50,,1.2,percent of total billed charges,50% of total billed charges,1.71,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.71,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.03,38,,1.624,percent of total billed charges,38% of total billed charges,2.14,40,,0.96,percent of total billed charges,40% of total billed charges,1.71,4.55,
nitroglycerin 0.4 mg sublingual Tab [FMC],2562965,CDM,250,RC,,,OUTPATIENT,1,EA,3.32,1.992,,2.82,85,,2.256,Percent of total billed charges,85% of total billed charges,1.66,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.66,50,,1.2,percent of total billed charges,50% of total billed charges,1.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.26,38,,1.008,percent of total billed charges,38% of total billed charges,1.33,40,,0.96,percent of total billed charges,40% of total billed charges,1.06,2.82,
nitroglycerin 0.4 mg sublingual Tab [FMC],2562965,CDM,250,RC,,,OUTPATIENT,1,EA,3.34,2.004,,2.84,85,,2.272,Percent of total billed charges,85% of total billed charges,1.67,50,,2.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.67,50,,1.2,percent of total billed charges,50% of total billed charges,1.07,31.95,,5.032,percent of total billed charges,31.95% of total billed charges,1.07,31.95,,374.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.27,38,,1.016,percent of total billed charges,38% of total billed charges,1.34,40,,4.576,percent of total billed charges,40% of total billed charges,1.07,2.84,
nitroglycerin 0.6 mg/hr Transderm ER Film [FMC],2562973,CDM,250,RC,,,OUTPATIENT,1,EA,6.71,4.026,,5.7,85,,4.56,Percent of total billed charges,85% of total billed charges,3.36,50,,2.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.36,50,,1.2,percent of total billed charges,50% of total billed charges,2.14,31.95,,18.848,percent of total billed charges,31.95% of total billed charges,2.14,31.95,,375.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.55,38,,2.04,percent of total billed charges,38% of total billed charges,2.68,40,,17.136,percent of total billed charges,40% of total billed charges,2.14,5.7,
nitroglycerin 0.6 mg/hr ER [FMC],2562973,CDM,250,RC,,,OUTPATIENT,1,EA,10.25,6.15,,8.71,85,,6.968,Percent of total billed charges,85% of total billed charges,5.13,50,,2.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.13,50,,1.2,percent of total billed charges,50% of total billed charges,3.27,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,3.27,31.95,,378.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.9,38,,3.12,percent of total billed charges,38% of total billed charges,4.1,40,,3.064,percent of total billed charges,40% of total billed charges,3.27,8.71,
nitroglycerin 0.6 mg/hr ER [FMC],2562973,CDM,250,RC,,,OUTPATIENT,1,EA,7.79,4.674,,6.62,85,,5.296,Percent of total billed charges,85% of total billed charges,3.9,50,,4.32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.9,50,,1.2,percent of total billed charges,50% of total billed charges,2.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.96,38,,2.368,percent of total billed charges,38% of total billed charges,3.12,40,,0.96,percent of total billed charges,40% of total billed charges,2.49,6.62,
nitroglycerin 2% Top UD Oint [FMC],2563013,CDM,250,RC,,,OUTPATIENT,1,F2,8.95,5.37,,7.61,85,,6.088,Percent of total billed charges,85% of total billed charges,4.48,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.48,50,,2.264,percent of total billed charges,50% of total billed charges,2.86,31.95,,64.856,percent of total billed charges,31.95% of total billed charges,2.86,31.95,,64.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.4,38,,2.72,percent of total billed charges,38% of total billed charges,3.58,40,,81.192,percent of total billed charges,40% of total billed charges,2.86,7.61,
nitrofurantoin macrocrystals 50 mg Cap [FMC],2563021,CDM,250,RC,,,OUTPATIENT,1,EA,14.36,8.616,,12.21,85,,9.768,Percent of total billed charges,85% of total billed charges,7.18,50,,4.536,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.18,50,,2.624,percent of total billed charges,50% of total billed charges,4.59,31.95,,45.952,percent of total billed charges,31.95% of total billed charges,4.59,31.95,,45.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.46,38,,4.368,percent of total billed charges,38% of total billed charges,5.74,40,,57.536,percent of total billed charges,40% of total billed charges,4.59,12.21,
nitrofurantoin macrocrystals 50 mg Cap [FMC],2563021,CDM,250,RC,,,OUTPATIENT,1,EA,14.36,8.616,,12.21,85,,9.768,Percent of total billed charges,85% of total billed charges,7.18,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.18,50,,2.624,percent of total billed charges,50% of total billed charges,4.59,31.95,,1.44,percent of total billed charges,31.95% of total billed charges,4.59,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.46,38,,4.368,percent of total billed charges,38% of total billed charges,5.74,40,,1.304,percent of total billed charges,40% of total billed charges,4.59,12.21,
nitrofurantoin macrocrystals 50 mg Cap [FMC],2563021,CDM,250,RC,,,OUTPATIENT,1,EA,6.94,4.164,,5.9,85,,4.72,Percent of total billed charges,85% of total billed charges,3.47,50,,5.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,3.328,percent of total billed charges,50% of total billed charges,2.22,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,2.22,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.64,38,,2.112,percent of total billed charges,38% of total billed charges,2.78,40,,0.768,percent of total billed charges,40% of total billed charges,2.22,5.9,
nitrofurantoin macrocrystals 50 mg Cap [FMC],2563021,CDM,250,RC,,,OUTPATIENT,1,EA,6.94,4.164,,5.9,85,,4.72,Percent of total billed charges,85% of total billed charges,3.47,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,23.696,percent of total billed charges,50% of total billed charges,2.22,31.95,,5.224,percent of total billed charges,31.95% of total billed charges,2.22,31.95,,5.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.64,38,,2.112,percent of total billed charges,38% of total billed charges,2.78,40,,6.544,percent of total billed charges,40% of total billed charges,2.22,5.9,
nitroprusside 25 mg/mL IV Sol [FMC],2563062,CDM,250,RC,,,OUTPATIENT,2,ML,837.85,502.71,,712.17,85,,569.736,Percent of total billed charges,85% of total billed charges,418.93,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,418.93,50,,18.8,percent of total billed charges,50% of total billed charges,267.69,31.95,,5.224,percent of total billed charges,31.95% of total billed charges,267.69,31.95,,5.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,318.38,38,,254.704,percent of total billed charges,38% of total billed charges,335.14,40,,6.544,percent of total billed charges,40% of total billed charges,267.69,712.17,
nitroprusside 25 mg/mL IV Sol [FMC],2563062,CDM,250,RC,,,OUTPATIENT,2,ML,3123.12,1873.872,,2654.65,85,,2123.72,Percent of total billed charges,85% of total billed charges,1561.56,50,,9.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1561.56,50,,20.096,percent of total billed charges,50% of total billed charges,997.84,31.95,,35.808,percent of total billed charges,31.95% of total billed charges,997.84,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1186.79,38,,949.432,percent of total billed charges,38% of total billed charges,1249.25,40,,32.552,percent of total billed charges,40% of total billed charges,997.84,2654.65,
nitroprusside 25 mg/mL IV Sol [FMC],2563062,CDM,250,RC,,,OUTPATIENT,2,ML,312,187.2,,265.2,85,,212.16,Percent of total billed charges,85% of total billed charges,156,50,,10.688,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,156,50,,1.6,percent of total billed charges,50% of total billed charges,99.68,31.95,,27.416,percent of total billed charges,31.95% of total billed charges,99.68,31.95,,384.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,118.56,38,,94.848,percent of total billed charges,38% of total billed charges,124.8,40,,24.92,percent of total billed charges,40% of total billed charges,99.68,265.2,
nitroprusside 25 mg/mL IV Sol [FMC],2563062,CDM,250,RC,,,OUTPATIENT,2,ML,1051.83,631.098,,894.06,85,,715.248,Percent of total billed charges,85% of total billed charges,525.92,50,,6.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,525.92,50,,1.6,percent of total billed charges,50% of total billed charges,336.06,31.95,,27.416,percent of total billed charges,31.95% of total billed charges,336.06,31.95,,396.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,399.7,38,,319.76,percent of total billed charges,38% of total billed charges,420.73,40,,24.92,percent of total billed charges,40% of total billed charges,336.06,894.06,
nitroprusside 25 mg/mL IV Sol [FMC],2563062,CDM,250,RC,,,OUTPATIENT,2,ML,81.25,48.75,,69.06,85,,55.248,Percent of total billed charges,85% of total billed charges,40.63,50,,9.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.63,50,,1.6,percent of total billed charges,50% of total billed charges,25.96,31.95,,29.992,percent of total billed charges,31.95% of total billed charges,25.96,31.95,,400.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.88,38,,24.704,percent of total billed charges,38% of total billed charges,32.5,40,,27.264,percent of total billed charges,40% of total billed charges,25.96,69.06,
ketoconazole Top 2% Shampoo [FMC],2563088,CDM,250,RC,,,OUTPATIENT,120,EA,90.29,54.174,,76.75,85,,61.4,Percent of total billed charges,85% of total billed charges,45.15,50,,2.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.15,50,,1.6,percent of total billed charges,50% of total billed charges,28.85,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,28.85,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.31,38,,27.448,percent of total billed charges,38% of total billed charges,36.12,40,,0.96,percent of total billed charges,40% of total billed charges,28.85,76.75,
ketoconazole Top 2% Shampoo [FMC],2563088,CDM,250,RC,,,OUTPATIENT,120,EA,90.19,54.114,,76.66,85,,61.328,Percent of total billed charges,85% of total billed charges,45.1,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.1,50,,2.088,percent of total billed charges,50% of total billed charges,28.82,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,28.82,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.27,38,,27.416,percent of total billed charges,38% of total billed charges,36.08,40,,1.016,percent of total billed charges,40% of total billed charges,28.82,76.66,
vecuronium 10 mg REC [FMC],2563104,CDM,250,RC,,,OUTPATIENT,1,EA,33.15,19.89,,28.18,85,,22.544,Percent of total billed charges,85% of total billed charges,16.58,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.58,50,,1.88,percent of total billed charges,50% of total billed charges,10.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,10.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.6,38,,10.08,percent of total billed charges,38% of total billed charges,13.26,40,,0.96,percent of total billed charges,40% of total billed charges,10.59,28.18,
vecuronium 10 mg REC [FMC],2563104,CDM,250,RC,,,OUTPATIENT,1,EA,19.5,11.7,,16.58,85,,13.264,Percent of total billed charges,85% of total billed charges,9.75,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.75,50,,2.088,percent of total billed charges,50% of total billed charges,6.23,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,6.23,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.41,38,,5.928,percent of total billed charges,38% of total billed charges,7.8,40,,0.992,percent of total billed charges,40% of total billed charges,6.23,16.58,
vecuronium 10 mg REC [FMC],2563104,CDM,250,RC,,,OUTPATIENT,1,EA,20.08,12.048,,17.07,85,,13.656,Percent of total billed charges,85% of total billed charges,10.04,50,,1.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.04,50,,2.088,percent of total billed charges,50% of total billed charges,6.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.63,38,,6.104,percent of total billed charges,38% of total billed charges,8.03,40,,0.96,percent of total billed charges,40% of total billed charges,6.42,17.07,
vecuronium 10 mg REC [FMC],2563104,CDM,250,RC,,,OUTPATIENT,1,EA,20.28,12.168,,17.24,85,,13.792,Percent of total billed charges,85% of total billed charges,10.14,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.14,50,,2.088,percent of total billed charges,50% of total billed charges,6.48,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,6.48,31.95,,0.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.71,38,,6.168,percent of total billed charges,38% of total billed charges,8.11,40,,1.008,percent of total billed charges,40% of total billed charges,6.48,17.24,
vecuronium 10 mg REC [FMC],2563104,CDM,250,RC,,,OUTPATIENT,1,EA,21.45,12.87,,18.23,85,,14.584,Percent of total billed charges,85% of total billed charges,10.73,50,,9.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.73,50,,2.088,percent of total billed charges,50% of total billed charges,6.85,31.95,,0.824,percent of total billed charges,31.95% of total billed charges,6.85,31.95,,0.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.15,38,,6.52,percent of total billed charges,38% of total billed charges,8.58,40,,1.032,percent of total billed charges,40% of total billed charges,6.85,18.23,
vecuronium 10 mg REC [FMC],2563104,CDM,250,RC,,,OUTPATIENT,1,EA,20.28,12.168,,17.24,85,,13.792,Percent of total billed charges,85% of total billed charges,10.14,50,,9.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.14,50,,1.88,percent of total billed charges,50% of total billed charges,6.48,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,6.48,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.71,38,,6.168,percent of total billed charges,38% of total billed charges,8.11,40,,1.288,percent of total billed charges,40% of total billed charges,6.48,17.24,
vecuronium 10 mg REC [FMC],2563104,CDM,250,RC,,,OUTPATIENT,1,EA,28.62,17.172,,24.33,85,,19.464,Percent of total billed charges,85% of total billed charges,14.31,50,,6.888,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.31,50,,2.088,percent of total billed charges,50% of total billed charges,9.14,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,9.14,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.88,38,,8.704,percent of total billed charges,38% of total billed charges,11.45,40,,0.96,percent of total billed charges,40% of total billed charges,9.14,24.33,
amLODIPine 5 mg Tab [FMC],2563179,CDM,250,RC,,,OUTPATIENT,1,EA,5.34,3.204,,4.54,85,,3.632,Percent of total billed charges,85% of total billed charges,2.67,50,,84.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.67,50,,2.4,percent of total billed charges,50% of total billed charges,1.71,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.71,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.03,38,,1.624,percent of total billed charges,38% of total billed charges,2.14,40,,0.96,percent of total billed charges,40% of total billed charges,1.71,4.54,
amLODIPine 5 mg Tab [FMC],2563179,CDM,250,RC,,,OUTPATIENT,1,EA,5.81,3.486,,4.94,85,,3.952,Percent of total billed charges,85% of total billed charges,2.91,50,,4.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.91,50,,2.4,percent of total billed charges,50% of total billed charges,1.86,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.86,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.21,38,,1.768,percent of total billed charges,38% of total billed charges,2.32,40,,0.96,percent of total billed charges,40% of total billed charges,1.86,4.94,
amLODIPine 5 mg Tab [FMC],2563179,CDM,250,RC,,,OUTPATIENT,1,EA,5.62,3.372,,4.78,85,,3.824,Percent of total billed charges,85% of total billed charges,2.81,50,,8.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.81,50,,2.472,percent of total billed charges,50% of total billed charges,1.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.14,38,,1.712,percent of total billed charges,38% of total billed charges,2.25,40,,0.96,percent of total billed charges,40% of total billed charges,1.8,4.78,
amLODIPine 5 mg Tab [FMC],2563179,CDM,250,RC,,,OUTPATIENT,1,EA,11.3,6.78,,9.61,85,,7.688,Percent of total billed charges,85% of total billed charges,5.65,50,,4.368,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.65,50,,18.176,percent of total billed charges,50% of total billed charges,3.61,31.95,,11.128,percent of total billed charges,31.95% of total billed charges,3.61,31.95,,11.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.29,38,,3.432,percent of total billed charges,38% of total billed charges,4.52,40,,13.936,percent of total billed charges,40% of total billed charges,3.61,9.61,
amLODIPine 5 mg Tab [FMC],2563179,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.328,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.448,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,10.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,13.088,percent of total billed charges,40% of total billed charges,0.96,2.55,
insulin isophane-insulin regular human recombinant 70 units-30 units/mL SubQ Inj 10 mL [FMC],2563195,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,35.21,21.126,,29.93,85,,23.944,Percent of total billed charges,85% of total billed charges,0.76,136.6,,21.832,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,4.608,fee schedule,136.60% of BCBS custom fee schedule,12.38,35.15,,175.744,fee schedule,35.15% of LA custom fee schedule,11.25,31.95,,175.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.38,38,,10.704,percent of total billed charges,38% of total billed charges,11.25,31.95,,220.024,Fee Schedule,31.95% of LA custom fee schedule,0.76,29.93,
insulin isophane-insulin regular human recombinant 70 units-30 units/mL Sus,2563195,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,57.99,34.794,,49.29,85,,39.432,Percent of total billed charges,85% of total billed charges,0.76,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,20.38,35.15,,37.464,fee schedule,35.15% of LA custom fee schedule,18.53,31.95,,37.464,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,17.632,percent of total billed charges,38% of total billed charges,18.53,31.95,,46.904,Fee Schedule,31.95% of LA custom fee schedule,0.76,49.29,
insulin aspart 100 units/mL SubQ Sol [FMC],2563203,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,112.85,67.71,,95.92,85,,76.736,Percent of total billed charges,85% of total billed charges,0.76,136.6,,11.504,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,39.67,35.15,,0.792,fee schedule,35.15% of LA custom fee schedule,36.06,31.95,,0.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.88,38,,34.304,percent of total billed charges,38% of total billed charges,36.06,31.95,,0.992,Fee Schedule,31.95% of LA custom fee schedule,0.76,95.92,
insulin aspart 100 units/mL SubQ Sol [FMC],2563203,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,28.21,16.926,,23.98,85,,19.184,Percent of total billed charges,85% of total billed charges,0.76,136.6,,22.088,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,9.92,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,9.01,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.72,38,,8.576,percent of total billed charges,38% of total billed charges,9.01,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.76,23.98,
Sodium Chloride 0.9% IV Sol 1000 mL [FMC],2563229,CDM,250,RC,J7030,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.88,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.88,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.84,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,400.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.768,Fee Schedule,31.95% of LA custom fee schedule,3.88,30.6,
Sodium Chloride 0.9% IV Sol 1000 mL [FMC],2563229,CDM,250,RC,J7030,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.88,136.6,,17.152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.88,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.84,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,403.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.768,Fee Schedule,31.95% of LA custom fee schedule,3.88,30.6,
Sodium Chloride 0.9% IV Sol 1000 mL [FMC],2563229,CDM,250,RC,J7030,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.88,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.88,136.6,,215.576,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.84,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,414.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.768,Fee Schedule,31.95% of LA custom fee schedule,3.88,30.6,
Sodium Chloride 0.9% IV Sol 1000 mL [FMC],2563229,CDM,250,RC,J7030,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,3.88,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.88,136.6,,19.504,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.84,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.768,Fee Schedule,31.95% of LA custom fee schedule,3.88,30.6,
Sodium Chloride 0.9% IV Sol 100 mL [FMC],2563237,CDM,250,RC,,,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,7.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,4.656,percent of total billed charges,50% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,0.96,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% IV Sol 100 mL [FMC],2563237,CDM,250,RC,,,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,9.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,63.376,percent of total billed charges,50% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,0.96,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% IV Sol 100 mL [FMC],2563237,CDM,250,RC,,,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,9.728,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,66.304,percent of total billed charges,50% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,0.96,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% IV Sol 100 mL [FMC],2563237,CDM,250,RC,,,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,10.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,66.304,percent of total billed charges,50% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,0.96,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% IV Sol 250 mL [FMC],2563245,CDM,250,RC,J7050,HCPCS,OUTPATIENT,250,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.98,136.6,,268.16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,17.16,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.98,30.6,
Sodium Chloride 0.9% IV Sol 250 mL [FMC],2563245,CDM,250,RC,J7050,HCPCS,OUTPATIENT,250,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.98,136.6,,327.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,14.432,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,2.848,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,2.584,Fee Schedule,31.95% of LA custom fee schedule,0.98,30.6,
Sodium Chloride 0.9% IV Sol 250 mL [FMC],2563245,CDM,250,RC,J7050,HCPCS,OUTPATIENT,250,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.98,136.6,,8.816,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,25.584,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,2.856,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,2.6,Fee Schedule,31.95% of LA custom fee schedule,0.98,30.6,
Sodium Chloride 0.9% IV Sol 250 mL [FMC],2563245,CDM,250,RC,J7050,HCPCS,OUTPATIENT,250,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.98,136.6,,7.936,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,18.928,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,2.856,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,2.6,Fee Schedule,31.95% of LA custom fee schedule,0.98,30.6,
Sodium Chloride 0.9% IV Sol 250 mL [FMC],2563245,CDM,250,RC,J7050,HCPCS,OUTPATIENT,250,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.98,136.6,,35.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,44.176,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,5.48,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,423.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,4.984,Fee Schedule,31.95% of LA custom fee schedule,0.98,30.6,
Sodium Chloride 0.9% IV Sol 50 mL [FMC],2563252,CDM,250,RC,,,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,20.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,8.128,percent of total billed charges,50% of total billed charges,11.5,31.95,,7.768,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,424.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,7.064,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% IV Sol 50 mL [FMC],2563252,CDM,250,RC,,,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,7.456,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,268.944,percent of total billed charges,50% of total billed charges,11.5,31.95,,5.512,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,426.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,5.008,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% IV Sol 50 mL [FMC],2563252,CDM,250,RC,,,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,5.512,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,356.008,percent of total billed charges,50% of total billed charges,11.5,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,426.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,5.064,percent of total billed charges,40% of total billed charges,11.5,30.6,
ADDvantage Sodium Chloride 0.9% 50mL IV Sol [FMC],2563252,CDM,250,RC,J7040,HCPCS,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.94,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.94,136.6,,9.056,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,7.768,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,433.496,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,7.064,Fee Schedule,31.95% of LA custom fee schedule,1.94,30.6,
Sodium Chloride 0.9% IV Sol 50 mL [FMC],2563252,CDM,250,RC,,,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,1.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,8.064,percent of total billed charges,50% of total billed charges,11.5,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,440.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,5.056,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% IV Sol 500 mL [FMC],2563260,CDM,250,RC,J7040,HCPCS,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.94,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.94,136.6,,3.288,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,4.568,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,454.968,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,4.152,Fee Schedule,31.95% of LA custom fee schedule,1.94,30.6,
Sodium Chloride 0.9% IV Sol 500 mL [FMC],2563260,CDM,250,RC,J7040,HCPCS,OUTPATIENT,500,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.94,136.6,,1.384,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.94,136.6,,2.736,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,4.376,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,4.376,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,5.48,Fee Schedule,31.95% of LA custom fee schedule,1.94,30.6,
"nystatin 100,000 units/ml 5ml Susp UD {FMC]",2563344,CDM,250,RC,,,OUTPATIENT,5,ML,3.28,1.968,,2.79,85,,2.232,Percent of total billed charges,85% of total billed charges,1.64,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.64,50,,1.52,percent of total billed charges,50% of total billed charges,1.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.25,38,,1,percent of total billed charges,38% of total billed charges,1.31,40,,0.96,percent of total billed charges,40% of total billed charges,1.05,2.79,
"nystatin 100,000 units/ml 5ml Susp UD {FMC]",2563344,CDM,250,RC,,,OUTPATIENT,5,ML,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,1.448,percent of total billed charges,50% of total billed charges,1.6,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,1.52,percent of total billed charges,38% of total billed charges,2,40,,0.96,percent of total billed charges,40% of total billed charges,1.6,4.25,
"nystatin 100,000 units/ml 5ml Susp UD {FMC]",2563344,CDM,250,RC,,,OUTPATIENT,5,ML,4.1,2.46,,3.49,85,,2.792,Percent of total billed charges,85% of total billed charges,2.05,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.05,50,,1.616,percent of total billed charges,50% of total billed charges,1.31,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,1.31,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.56,38,,1.248,percent of total billed charges,38% of total billed charges,1.64,40,,4.248,percent of total billed charges,40% of total billed charges,1.31,3.49,
"nystatin 100,000 units/ml 5ml Susp UD {FMC]",2563344,CDM,250,RC,,,OUTPATIENT,5,ML,7.8,4.68,,6.63,85,,5.304,Percent of total billed charges,85% of total billed charges,3.9,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.9,50,,1.448,percent of total billed charges,50% of total billed charges,2.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.96,38,,2.368,percent of total billed charges,38% of total billed charges,3.12,40,,0.96,percent of total billed charges,40% of total billed charges,2.49,6.63,
"nystatin 100,000 units/ml 5ml Susp UD {FMC]",2563344,CDM,250,RC,,,OUTPATIENT,5,ML,5.46,3.276,,4.64,85,,3.712,Percent of total billed charges,85% of total billed charges,2.73,50,,5.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.73,50,,1.432,percent of total billed charges,50% of total billed charges,1.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.07,38,,1.656,percent of total billed charges,38% of total billed charges,2.18,40,,0.96,percent of total billed charges,40% of total billed charges,1.74,4.64,
"nystatin Top 100,000 units/g Crm [FMC]",2563369,CDM,250,RC,,,OUTPATIENT,15,EA,57.04,34.224,,48.48,85,,38.784,Percent of total billed charges,85% of total billed charges,28.52,50,,5.744,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.52,50,,1.448,percent of total billed charges,50% of total billed charges,18.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,18.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.68,38,,17.344,percent of total billed charges,38% of total billed charges,22.82,40,,0.96,percent of total billed charges,40% of total billed charges,18.22,48.48,
"nystatin Top 100,000 units/g Crm [FMC]",2563369,CDM,250,RC,,,OUTPATIENT,15,EA,56.88,34.128,,48.35,85,,38.68,Percent of total billed charges,85% of total billed charges,28.44,50,,1.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.44,50,,1.616,percent of total billed charges,50% of total billed charges,18.17,31.95,,99.048,percent of total billed charges,31.95% of total billed charges,18.17,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.61,38,,17.288,percent of total billed charges,38% of total billed charges,22.75,40,,90.024,percent of total billed charges,40% of total billed charges,18.17,48.35,
"nystatin Top 100,000 units/g Crm [FMC]",2563369,CDM,250,RC,,,OUTPATIENT,15,EA,56.88,34.128,,48.35,85,,38.68,Percent of total billed charges,85% of total billed charges,28.44,50,,14.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.44,50,,1.432,percent of total billed charges,50% of total billed charges,18.17,31.95,,95.08,percent of total billed charges,31.95% of total billed charges,18.17,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.61,38,,17.288,percent of total billed charges,38% of total billed charges,22.75,40,,86.424,percent of total billed charges,40% of total billed charges,18.17,48.35,
"nystatin Top 100,000 units/g Crm [FMC]",2563369,CDM,250,RC,,,OUTPATIENT,15,EA,42.66,25.596,,36.26,85,,29.008,Percent of total billed charges,85% of total billed charges,21.33,50,,14.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.33,50,,1.6,percent of total billed charges,50% of total billed charges,13.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.21,38,,12.968,percent of total billed charges,38% of total billed charges,17.06,40,,0.96,percent of total billed charges,40% of total billed charges,13.63,36.26,
nystatin topical 100000 units/g Ointment 15 gm [FMC],2563377,CDM,250,RC,,,OUTPATIENT,15,EA,54.6,32.76,,46.41,85,,37.128,Percent of total billed charges,85% of total billed charges,27.3,50,,9.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.3,50,,1.6,percent of total billed charges,50% of total billed charges,17.44,31.95,,2.608,percent of total billed charges,31.95% of total billed charges,17.44,31.95,,2.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.75,38,,16.6,percent of total billed charges,38% of total billed charges,21.84,40,,3.264,percent of total billed charges,40% of total billed charges,17.44,46.41,
nystatin topical 100000 units/g Ointment 15 gm [FMC],2563377,CDM,250,RC,,,OUTPATIENT,15,EA,56.88,34.128,,48.35,85,,38.68,Percent of total billed charges,85% of total billed charges,28.44,50,,9.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.44,50,,1.6,percent of total billed charges,50% of total billed charges,18.17,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,18.17,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.61,38,,17.288,percent of total billed charges,38% of total billed charges,22.75,40,,0.96,percent of total billed charges,40% of total billed charges,18.17,48.35,
nystatin topical 100000 units/g Ointment 15 gm [FMC],2563377,CDM,250,RC,,,OUTPATIENT,15,EA,56.88,34.128,,48.35,85,,38.68,Percent of total billed charges,85% of total billed charges,28.44,50,,35.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.44,50,,1.6,percent of total billed charges,50% of total billed charges,18.17,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,18.17,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.61,38,,17.288,percent of total billed charges,38% of total billed charges,22.75,40,,1.04,percent of total billed charges,40% of total billed charges,18.17,48.35,
azelastine 0.05% Ophth Sol [FMC],2563484,CDM,250,RC,,,OUTPATIENT,6,EA,338.19,202.914,,287.46,85,,229.968,Percent of total billed charges,85% of total billed charges,169.1,50,,21.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,169.1,50,,1.6,percent of total billed charges,50% of total billed charges,108.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,108.05,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.51,38,,102.808,percent of total billed charges,38% of total billed charges,135.28,40,,0.96,percent of total billed charges,40% of total billed charges,108.05,287.46,
azelastine 0.05% Ophth Sol [FMC],2563484,CDM,250,RC,,,OUTPATIENT,6,EA,334.43,200.658,,284.27,85,,227.416,Percent of total billed charges,85% of total billed charges,167.22,50,,21.968,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,167.22,50,,1.6,percent of total billed charges,50% of total billed charges,106.85,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,106.85,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.08,38,,101.664,percent of total billed charges,38% of total billed charges,133.77,40,,1.112,percent of total billed charges,40% of total billed charges,106.85,284.27,
azelastine 0.05% Ophth Sol [FMC],2563484,CDM,250,RC,,,OUTPATIENT,6,EA,338.19,202.914,,287.46,85,,229.968,Percent of total billed charges,85% of total billed charges,169.1,50,,17.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,169.1,50,,1.6,percent of total billed charges,50% of total billed charges,108.05,31.95,,5.96,percent of total billed charges,31.95% of total billed charges,108.05,31.95,,5.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.51,38,,102.808,percent of total billed charges,38% of total billed charges,135.28,40,,7.464,percent of total billed charges,40% of total billed charges,108.05,287.46,
oxybutynin 5 mg Tab [FMC],2563591,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,27.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.224,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.032,percent of total billed charges,40% of total billed charges,0.96,2.55,
oxybutynin 5 mg Tab [FMC],2563591,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,67.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.12,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.16,percent of total billed charges,40% of total billed charges,0.96,2.55,
oxybutynin 5 mg Tab [FMC],2563591,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,73.856,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.792,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,12.264,percent of total billed charges,40% of total billed charges,0.96,2.55,
oxyCODONE 10 mg ER [FMC],2563609,CDM,250,RC,,,OUTPATIENT,1,EA,10.87,6.522,,9.24,85,,7.392,Percent of total billed charges,85% of total billed charges,5.44,50,,47.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.44,50,,2.472,percent of total billed charges,50% of total billed charges,3.47,31.95,,7.128,percent of total billed charges,31.95% of total billed charges,3.47,31.95,,7.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.13,38,,3.304,percent of total billed charges,38% of total billed charges,4.35,40,,8.928,percent of total billed charges,40% of total billed charges,3.47,9.24,
oxyCODONE 10 mg ER [FMC],2563609,CDM,250,RC,,,OUTPATIENT,1,EA,18.66,11.196,,15.86,85,,12.688,Percent of total billed charges,85% of total billed charges,9.33,50,,71.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.33,50,,3.376,percent of total billed charges,50% of total billed charges,5.96,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,5.96,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.09,38,,5.672,percent of total billed charges,38% of total billed charges,7.46,40,,3.528,percent of total billed charges,40% of total billed charges,5.96,15.86,
olopatadine Ophth 0.1% Sol [FMC],2563864,CDM,250,RC,,,OUTPATIENT,5,EA,705.77,423.462,,599.9,85,,479.92,Percent of total billed charges,85% of total billed charges,352.89,50,,68.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,352.89,50,,2.472,percent of total billed charges,50% of total billed charges,225.49,31.95,,2.376,percent of total billed charges,31.95% of total billed charges,225.49,31.95,,2.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,268.19,38,,214.552,percent of total billed charges,38% of total billed charges,282.31,40,,2.976,percent of total billed charges,40% of total billed charges,225.49,599.9,
olopatadine Ophth 0.1% Sol [FMC],2563864,CDM,250,RC,,,OUTPATIENT,5,EA,596.99,358.194,,507.44,85,,405.952,Percent of total billed charges,85% of total billed charges,298.5,50,,21.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,298.5,50,,1.2,percent of total billed charges,50% of total billed charges,190.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,190.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,226.86,38,,181.488,percent of total billed charges,38% of total billed charges,238.8,40,,0.96,percent of total billed charges,40% of total billed charges,190.74,507.44,
olopatadine Ophth 0.1% Sol [FMC],2563864,CDM,250,RC,,,OUTPATIENT,5,EA,833.63,500.178,,708.59,85,,566.872,Percent of total billed charges,85% of total billed charges,416.82,50,,9.912,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,416.82,50,,1.2,percent of total billed charges,50% of total billed charges,266.34,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,266.34,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,316.78,38,,253.424,percent of total billed charges,38% of total billed charges,333.45,40,,2.6,percent of total billed charges,40% of total billed charges,266.34,708.59,
olopatadine Ophth 0.1% Sol [FMC],2563864,CDM,250,RC,,,OUTPATIENT,5,EA,44.85,26.91,,38.12,85,,30.496,Percent of total billed charges,85% of total billed charges,22.43,50,,9.912,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.43,50,,1.2,percent of total billed charges,50% of total billed charges,14.33,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.33,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.04,38,,13.632,percent of total billed charges,38% of total billed charges,17.94,40,,0.96,percent of total billed charges,40% of total billed charges,14.33,38.12,
olopatadine Ophth 0.1% Sol [FMC],2563864,CDM,250,RC,,,OUTPATIENT,5,EA,101.56,60.936,,86.33,85,,69.064,Percent of total billed charges,85% of total billed charges,50.78,50,,14.912,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.78,50,,1.4,percent of total billed charges,50% of total billed charges,32.45,31.95,,10.728,percent of total billed charges,31.95% of total billed charges,32.45,31.95,,10.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.59,38,,30.872,percent of total billed charges,38% of total billed charges,40.62,40,,13.424,percent of total billed charges,40% of total billed charges,32.45,86.33,
PARoxetine 20 mg Tab [FMC],2563906,CDM,250,RC,,,OUTPATIENT,1,EA,8.86,5.316,,7.53,85,,6.024,Percent of total billed charges,85% of total billed charges,4.43,50,,14.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.43,50,,1.2,percent of total billed charges,50% of total billed charges,2.83,31.95,,10.192,percent of total billed charges,31.95% of total billed charges,2.83,31.95,,10.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.37,38,,2.696,percent of total billed charges,38% of total billed charges,3.54,40,,12.76,percent of total billed charges,40% of total billed charges,2.83,7.53,
PARoxetine 20 mg Tab [FMC],2563906,CDM,250,RC,,,OUTPATIENT,1,EA,9.54,5.724,,8.11,85,,6.488,Percent of total billed charges,85% of total billed charges,4.77,50,,14.32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.77,50,,1.2,percent of total billed charges,50% of total billed charges,3.05,31.95,,1.208,percent of total billed charges,31.95% of total billed charges,3.05,31.95,,1.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.63,38,,2.904,percent of total billed charges,38% of total billed charges,3.82,40,,1.52,percent of total billed charges,40% of total billed charges,3.05,8.11,
PARoxetine 20 mg Tab [FMC],2563906,CDM,250,RC,,,OUTPATIENT,1,EA,9.06,5.436,,7.7,85,,6.16,Percent of total billed charges,85% of total billed charges,4.53,50,,13.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.53,50,,1.4,percent of total billed charges,50% of total billed charges,2.89,31.95,,1.312,percent of total billed charges,31.95% of total billed charges,2.89,31.95,,1.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.44,38,,2.752,percent of total billed charges,38% of total billed charges,3.62,40,,1.64,percent of total billed charges,40% of total billed charges,2.89,7.7,
Penicillin V Potassium 500 mg Tab [FMC],2563955,CDM,250,RC,,,OUTPATIENT,1,EA,3.79,2.274,,3.22,85,,2.576,Percent of total billed charges,85% of total billed charges,1.9,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.9,50,,7.584,percent of total billed charges,50% of total billed charges,1.21,31.95,,1.648,percent of total billed charges,31.95% of total billed charges,1.21,31.95,,1.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.44,38,,1.152,percent of total billed charges,38% of total billed charges,1.52,40,,2.064,percent of total billed charges,40% of total billed charges,1.21,3.22,
Penicillin V Potassium 500 mg Tab [FMC],2563955,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.256,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.976,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.728,percent of total billed charges,40% of total billed charges,0.96,2.55,
pentoxifylline 400 mg ER  UD [FMC],2563971,CDM,250,RC,,,OUTPATIENT,1,EA,4.87,2.922,,4.14,85,,3.312,Percent of total billed charges,85% of total billed charges,2.44,50,,1.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.44,50,,7.168,percent of total billed charges,50% of total billed charges,1.56,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,1.56,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.85,38,,1.48,percent of total billed charges,38% of total billed charges,1.95,40,,2.096,percent of total billed charges,40% of total billed charges,1.56,4.14,
pentoxifylline 400 mg ER  UD [FMC],2563971,CDM,250,RC,,,OUTPATIENT,1,EA,4.87,2.922,,4.14,85,,3.312,Percent of total billed charges,85% of total billed charges,2.44,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.44,50,,3.568,percent of total billed charges,50% of total billed charges,1.56,31.95,,3.24,percent of total billed charges,31.95% of total billed charges,1.56,31.95,,3.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.85,38,,1.48,percent of total billed charges,38% of total billed charges,1.95,40,,4.056,percent of total billed charges,40% of total billed charges,1.56,4.14,
acetaminophen-oxyCODONE 325 mg-5 mg Tab [FMC],2564037,CDM,250,RC,,,OUTPATIENT,1,EA,4.45,2.67,,3.78,85,,3.024,Percent of total billed charges,85% of total billed charges,2.23,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.23,50,,4.144,percent of total billed charges,50% of total billed charges,1.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.69,38,,1.352,percent of total billed charges,38% of total billed charges,1.78,40,,0.96,percent of total billed charges,40% of total billed charges,1.42,3.78,
acetaminophen-oxyCODONE 325 mg-5 mg Tab [FMC],2564037,CDM,250,RC,,,OUTPATIENT,1,EA,4.45,2.67,,3.78,85,,3.024,Percent of total billed charges,85% of total billed charges,2.23,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.23,50,,7.288,percent of total billed charges,50% of total billed charges,1.42,31.95,,3.792,percent of total billed charges,31.95% of total billed charges,1.42,31.95,,3.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.69,38,,1.352,percent of total billed charges,38% of total billed charges,1.78,40,,4.744,percent of total billed charges,40% of total billed charges,1.42,3.78,
acetaminophen-oxyCODONE 325 mg-5 mg Tab [FMC],2564037,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,5.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,104.768,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.952,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,2.448,percent of total billed charges,40% of total billed charges,1.28,3.4,
acetaminophen-oxyCODONE 325 mg-5 mg Tab [FMC],2564037,CDM,250,RC,,,OUTPATIENT,1,EA,4.44,2.664,,3.77,85,,3.016,Percent of total billed charges,85% of total billed charges,2.22,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.22,50,,107.944,percent of total billed charges,50% of total billed charges,1.42,31.95,,3.776,percent of total billed charges,31.95% of total billed charges,1.42,31.95,,3.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.69,38,,1.352,percent of total billed charges,38% of total billed charges,1.78,40,,4.72,percent of total billed charges,40% of total billed charges,1.42,3.77,
acetaminophen-oxyCODONE 325 mg-5 mg Tab [FMC],2564037,CDM,250,RC,,,OUTPATIENT,1,EA,4.45,2.67,,3.78,85,,3.024,Percent of total billed charges,85% of total billed charges,2.23,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.23,50,,1.96,percent of total billed charges,50% of total billed charges,1.42,31.95,,47.816,percent of total billed charges,31.95% of total billed charges,1.42,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.69,38,,1.352,percent of total billed charges,38% of total billed charges,1.78,40,,43.464,percent of total billed charges,40% of total billed charges,1.42,3.78,
phenytoin 50 mg/mL Inj Sol [FMC],2564177,CDM,250,RC,J1165,HCPCS,OUTPATIENT,2,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.7,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.7,136.6,,1.984,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,31.64,percent of total billed charges,35.15% of total billed charges,385,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,28.76,percent of total billed charges,31.95% of total billed charges,0.7,385,
phenytoin 50 mg/mL Inj Sol [FMC],2564177,CDM,250,RC,J1165,HCPCS,OUTPATIENT,2,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.7,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.7,136.6,,1.872,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,65.144,percent of total billed charges,35.15% of total billed charges,389.79,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,59.216,percent of total billed charges,31.95% of total billed charges,0.7,389.79,
phenylephrine 10 mg/mL Inj Sol [FMC],2564185,CDM,250,RC,J2370,HCPCS,OUTPATIENT,1,ML,15.6,9.36,,13.26,85,,10.608,Percent of total billed charges,85% of total billed charges,7.8,50,,2.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.8,50,,1.96,percent of total billed charges,50% of total billed charges,5.48,35.15,,9.872,percent of total billed charges,35.15% of total billed charges,396.18,31.95,,458.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.93,38,,4.744,percent of total billed charges,38% of total billed charges,4.98,31.95,,8.968,percent of total billed charges,31.95% of total billed charges,4.98,396.18,
phenylephrine 10 mg/mL Inj Sol [FMC],2564185,CDM,250,RC,J2370,HCPCS,OUTPATIENT,1,ML,13.95,8.37,,11.86,85,,9.488,Percent of total billed charges,85% of total billed charges,6.98,50,,2.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.98,50,,14.696,percent of total billed charges,50% of total billed charges,4.9,35.15,,62.808,percent of total billed charges,35.15% of total billed charges,397.78,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.3,38,,4.24,percent of total billed charges,38% of total billed charges,4.46,31.95,,57.088,percent of total billed charges,31.95% of total billed charges,4.46,397.78,
phenylephrine 10 mg/mL Inj Sol [FMC],2564185,CDM,250,RC,J2370,HCPCS,OUTPATIENT,1,ML,12.48,7.488,,10.61,85,,8.488,Percent of total billed charges,85% of total billed charges,6.24,50,,2.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.24,50,,13.864,percent of total billed charges,50% of total billed charges,4.39,35.15,,50.264,percent of total billed charges,35.15% of total billed charges,410.56,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.74,38,,3.792,percent of total billed charges,38% of total billed charges,3.99,31.95,,45.688,percent of total billed charges,31.95% of total billed charges,3.99,410.56,
promethazine 12.5 mg Supp [FMC],2564193,CDM,250,RC,,,OUTPATIENT,1,EA,57.54,34.524,,48.91,85,,39.128,Percent of total billed charges,85% of total billed charges,28.77,50,,2.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.77,50,,8.12,percent of total billed charges,50% of total billed charges,18.38,31.95,,29.824,percent of total billed charges,31.95% of total billed charges,18.38,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.87,38,,17.496,percent of total billed charges,38% of total billed charges,23.02,40,,27.104,percent of total billed charges,40% of total billed charges,18.38,48.91,
promethazine 12.5 mg Supp [FMC],2564193,CDM,250,RC,,,OUTPATIENT,1,EA,57.54,34.524,,48.91,85,,39.128,Percent of total billed charges,85% of total billed charges,28.77,50,,2.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.77,50,,10.336,percent of total billed charges,50% of total billed charges,18.38,31.95,,40.616,percent of total billed charges,31.95% of total billed charges,18.38,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.87,38,,17.496,percent of total billed charges,38% of total billed charges,23.02,40,,36.92,percent of total billed charges,40% of total billed charges,18.38,48.91,
phenazopyridine 200 mg Tab [FMC],2564201,CDM,250,RC,,,OUTPATIENT,1,EA,3.04,1.824,,2.58,85,,2.064,Percent of total billed charges,85% of total billed charges,1.52,50,,518.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.52,50,,3.904,percent of total billed charges,50% of total billed charges,0.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.16,38,,0.928,percent of total billed charges,38% of total billed charges,1.22,40,,0.96,percent of total billed charges,40% of total billed charges,0.97,2.58,
phenazopyridine 200 mg Tab [FMC],2564201,CDM,250,RC,,,OUTPATIENT,1,EA,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,518.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,1.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,1.088,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,1.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,3.952,percent of total billed charges,38% of total billed charges,5.2,40,,1.368,percent of total billed charges,40% of total billed charges,4.15,11.05,
phenazopyridine 200 mg Tab [FMC],2564201,CDM,250,RC,,,OUTPATIENT,1,EA,11.7,7.02,,9.95,85,,7.96,Percent of total billed charges,85% of total billed charges,5.85,50,,10.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.85,50,,1.2,percent of total billed charges,50% of total billed charges,3.74,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,3.74,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.45,38,,3.56,percent of total billed charges,38% of total billed charges,4.68,40,,1.344,percent of total billed charges,40% of total billed charges,3.74,9.95,
phenazopyridine 200 mg Tab [FMC],2564201,CDM,250,RC,,,OUTPATIENT,1,EA,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,20.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,1.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,3.952,percent of total billed charges,38% of total billed charges,5.2,40,,1.296,percent of total billed charges,40% of total billed charges,4.15,11.05,
PHENobarbital 20 mg/5 mL Oral Elix [FMC],2564219,CDM,250,RC,,,OUTPATIENT,5,ML,3.44,2.064,,2.92,85,,2.336,Percent of total billed charges,85% of total billed charges,1.72,50,,6.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.72,50,,1.2,percent of total billed charges,50% of total billed charges,1.1,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,1.1,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,1.352,percent of total billed charges,40% of total billed charges,1.1,2.92,
PHENobarbital 20 mg/5 mL Oral Elix [FMC],2564219,CDM,250,RC,,,OUTPATIENT,5,ML,3.15,1.89,,2.68,85,,2.144,Percent of total billed charges,85% of total billed charges,1.58,50,,12.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.58,50,,4.232,percent of total billed charges,50% of total billed charges,1.01,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,1.01,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.2,38,,0.96,percent of total billed charges,38% of total billed charges,1.26,40,,1.312,percent of total billed charges,40% of total billed charges,1.01,2.68,
PHENobarbital 20 mg/5 mL Oral Elix [FMC],2564219,CDM,250,RC,,,OUTPATIENT,5,ML,17.4,10.44,,14.79,85,,11.832,Percent of total billed charges,85% of total billed charges,8.7,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.7,50,,4.232,percent of total billed charges,50% of total billed charges,5.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.61,38,,5.288,percent of total billed charges,38% of total billed charges,6.96,40,,0.96,percent of total billed charges,40% of total billed charges,5.56,14.79,
PHENobarbital 20 mg/5 mL Oral Elix [FMC],2564219,CDM,250,RC,,,OUTPATIENT,5,ML,17.4,10.44,,14.79,85,,11.832,Percent of total billed charges,85% of total billed charges,8.7,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.7,50,,4.352,percent of total billed charges,50% of total billed charges,5.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.61,38,,5.288,percent of total billed charges,38% of total billed charges,6.96,40,,0.96,percent of total billed charges,40% of total billed charges,5.56,14.79,
phenytoin 50 mg/mL 5ml Inj Sol [FMC],2564227,CDM,250,RC,J1165,HCPCS,OUTPATIENT,5,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.7,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.7,136.6,,3.176,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,6.752,percent of total billed charges,35.15% of total billed charges,423.34,31.95,,6.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,8.448,percent of total billed charges,31.95% of total billed charges,0.7,423.34,
phenytoin 50 mg/mL 5ml Inj Sol [FMC],2564227,CDM,250,RC,J1165,HCPCS,OUTPATIENT,5,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.7,136.6,,351.136,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.7,136.6,,3.704,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,6.76,percent of total billed charges,35.15% of total billed charges,433.88,31.95,,6.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,8.464,percent of total billed charges,31.95% of total billed charges,0.7,433.88,
promethazine 25 mg Supp [FMC],2564235,CDM,250,RC,,,OUTPATIENT,1,EA,57.54,34.524,,48.91,85,,39.128,Percent of total billed charges,85% of total billed charges,28.77,50,,5.656,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.77,50,,3.344,percent of total billed charges,50% of total billed charges,18.38,31.95,,6.48,percent of total billed charges,31.95% of total billed charges,18.38,31.95,,6.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.87,38,,17.496,percent of total billed charges,38% of total billed charges,23.02,40,,8.112,percent of total billed charges,40% of total billed charges,18.38,48.91,
phentolamine 5 mg REC [FMC],2564276,CDM,250,RC,J2760,HCPCS,OUTPATIENT,1,EA,1910.88,1146.528,,1624.25,85,,1299.4,Percent of total billed charges,85% of total billed charges,681.67,136.6,,3.224,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,681.67,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,671.67,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,434.2,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,726.13,38,,580.904,percent of total billed charges,38% of total billed charges,610.53,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,434.2,1624.25,
phentolamine 5 mg REC [FMC],2564276,CDM,250,RC,J2760,HCPCS,OUTPATIENT,1,EA,1637.22,982.332,,1391.64,85,,1113.312,Percent of total billed charges,85% of total billed charges,681.67,136.6,,5.968,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,681.67,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,575.48,35.15,,0.776,percent of total billed charges,35.15% of total billed charges,445.7,31.95,,0.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.14,38,,497.712,percent of total billed charges,38% of total billed charges,523.09,31.95,,0.976,percent of total billed charges,31.95% of total billed charges,445.7,1391.64,
codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup [FMC],2564292,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.36,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.704,percent of total billed charges,40% of total billed charges,0.96,2.55,
codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup [FMC],2564292,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup [FMC],2564292,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.448,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.36,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.704,percent of total billed charges,40% of total billed charges,0.96,2.55,
codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup [FMC],2564292,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.416,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.776,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium acetate 667 mg Cap UD [FMC],2564359,CDM,250,RC,,,OUTPATIENT,1,EA,5.46,3.276,,4.64,85,,3.712,Percent of total billed charges,85% of total billed charges,2.73,50,,10.448,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.73,50,,1.2,percent of total billed charges,50% of total billed charges,1.74,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,1.74,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.07,38,,1.656,percent of total billed charges,38% of total billed charges,2.18,40,,2.6,percent of total billed charges,40% of total billed charges,1.74,4.64,
calcium acetate 667 mg Cap UD [FMC],2564359,CDM,250,RC,,,OUTPATIENT,1,EA,5.68,3.408,,4.83,85,,3.864,Percent of total billed charges,85% of total billed charges,2.84,50,,12.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.84,50,,1.2,percent of total billed charges,50% of total billed charges,1.81,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,1.81,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.16,38,,1.728,percent of total billed charges,38% of total billed charges,2.27,40,,1.976,percent of total billed charges,40% of total billed charges,1.81,4.83,
calcium acetate 667 mg Cap UD [FMC],2564359,CDM,250,RC,,,OUTPATIENT,1,EA,3.34,2.004,,2.84,85,,2.272,Percent of total billed charges,85% of total billed charges,1.67,50,,12.496,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.67,50,,1.2,percent of total billed charges,50% of total billed charges,1.07,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,1.07,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.27,38,,1.016,percent of total billed charges,38% of total billed charges,1.34,40,,1.976,percent of total billed charges,40% of total billed charges,1.07,2.84,
calcium acetate 667 mg Cap UD [FMC],2564359,CDM,250,RC,,,OUTPATIENT,1,EA,5.6,3.36,,4.76,85,,3.808,Percent of total billed charges,85% of total billed charges,2.8,50,,8.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.8,50,,3.24,percent of total billed charges,50% of total billed charges,1.79,31.95,,1.416,percent of total billed charges,31.95% of total billed charges,1.79,31.95,,1.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.13,38,,1.704,percent of total billed charges,38% of total billed charges,2.24,40,,1.776,percent of total billed charges,40% of total billed charges,1.79,4.76,
phytonadione 10 mg/mL Inj Sol [FMC],2564375,CDM,250,RC,J3430,HCPCS,OUTPATIENT,1,ML,190.97,114.582,,162.32,85,,129.856,Percent of total billed charges,85% of total billed charges,4.48,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.48,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,67.13,35.15,,1.624,percent of total billed charges,35.15% of total billed charges,447.3,31.95,,1.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,72.57,38,,58.056,percent of total billed charges,38% of total billed charges,61.01,31.95,,2.032,percent of total billed charges,31.95% of total billed charges,4.48,447.3,
phytonadione 10 mg/mL Inj Sol [FMC],2564375,CDM,250,RC,J3430,HCPCS,OUTPATIENT,1,ML,166.79,100.074,,141.77,85,,113.416,Percent of total billed charges,85% of total billed charges,4.48,136.6,,1.352,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.48,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,58.63,35.15,,1.536,percent of total billed charges,35.15% of total billed charges,447.3,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.38,38,,50.704,percent of total billed charges,38% of total billed charges,53.29,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,4.48,447.3,
pilocarpine Ophth 4% Sol [FMC],2564409,CDM,250,RC,,,OUTPATIENT,15,EA,143,85.8,,121.55,85,,97.24,Percent of total billed charges,85% of total billed charges,71.5,50,,18.824,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,71.5,50,,4.064,percent of total billed charges,50% of total billed charges,45.69,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,45.69,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.34,38,,43.472,percent of total billed charges,38% of total billed charges,57.2,40,,1.92,percent of total billed charges,40% of total billed charges,45.69,121.55,
bismuth subsalicylate 262 mg/15 mL Sus [FMC],2564441,CDM,250,RC,,,OUTPATIENT,15,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.808,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
bismuth subsalicylate 262 mg/15 mL Sus [FMC],2564441,CDM,250,RC,,,OUTPATIENT,15,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.32,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
clopidogrel 75 mg Tab UD [FMC],2564466,CDM,250,RC,,,OUTPATIENT,1,EA,22.14,13.284,,18.82,85,,15.056,Percent of total billed charges,85% of total billed charges,11.07,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.07,50,,3.472,percent of total billed charges,50% of total billed charges,7.07,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.07,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.41,38,,6.728,percent of total billed charges,38% of total billed charges,8.86,40,,0.96,percent of total billed charges,40% of total billed charges,7.07,18.82,
clopidogrel 75 mg Tab UD [FMC],2564466,CDM,250,RC,,,OUTPATIENT,1,EA,14.18,8.508,,12.05,85,,9.64,Percent of total billed charges,85% of total billed charges,7.09,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.09,50,,1.2,percent of total billed charges,50% of total billed charges,4.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.39,38,,4.312,percent of total billed charges,38% of total billed charges,5.67,40,,0.96,percent of total billed charges,40% of total billed charges,4.53,12.05,
clopidogrel 75 mg Tab,2564466,CDM,250,RC,,,OUTPATIENT,1,EA,22.62,13.572,,19.23,85,,15.384,Percent of total billed charges,85% of total billed charges,11.31,50,,37.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.31,50,,3.472,percent of total billed charges,50% of total billed charges,7.23,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.23,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.6,38,,6.88,percent of total billed charges,38% of total billed charges,9.05,40,,0.96,percent of total billed charges,40% of total billed charges,7.23,19.23,
clopidogrel 75 mg Tab UD [FMC],2564466,CDM,250,RC,,,OUTPATIENT,1,EA,22.59,13.554,,19.2,85,,15.36,Percent of total billed charges,85% of total billed charges,11.3,50,,6.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.3,50,,331.312,percent of total billed charges,50% of total billed charges,7.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.58,38,,6.864,percent of total billed charges,38% of total billed charges,9.04,40,,0.96,percent of total billed charges,40% of total billed charges,7.22,19.2,
cilostazol 100 mg Tab [FMC],2564482,CDM,250,RC,,,OUTPATIENT,1,EA,5.93,3.558,,5.04,85,,4.032,Percent of total billed charges,85% of total billed charges,2.97,50,,4.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.97,50,,35.88,percent of total billed charges,50% of total billed charges,1.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.25,38,,1.8,percent of total billed charges,38% of total billed charges,2.37,40,,0.96,percent of total billed charges,40% of total billed charges,1.89,5.04,
cilostazol 100 mg Tab [FMC],2564482,CDM,250,RC,,,OUTPATIENT,1,EA,5.93,3.558,,5.04,85,,4.032,Percent of total billed charges,85% of total billed charges,2.97,50,,3.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.97,50,,1.872,percent of total billed charges,50% of total billed charges,1.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.25,38,,1.8,percent of total billed charges,38% of total billed charges,2.37,40,,0.96,percent of total billed charges,40% of total billed charges,1.89,5.04,
cilostazol 100 mg Tab [FMC],2564482,CDM,250,RC,,,OUTPATIENT,1,EA,5.93,3.558,,5.04,85,,4.032,Percent of total billed charges,85% of total billed charges,2.97,50,,3.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.97,50,,3.24,percent of total billed charges,50% of total billed charges,1.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.25,38,,1.8,percent of total billed charges,38% of total billed charges,2.37,40,,0.96,percent of total billed charges,40% of total billed charges,1.89,5.04,
potassium chloride 10 mEq ER [FMC],2564540,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,37.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,19.792,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 10 mEq ER [FMC],2564540,CDM,250,RC,,,OUTPATIENT,1,EA,4.88,2.928,,4.15,85,,3.32,Percent of total billed charges,85% of total billed charges,2.44,50,,35.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.44,50,,19.648,percent of total billed charges,50% of total billed charges,1.56,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.56,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.85,38,,1.48,percent of total billed charges,38% of total billed charges,1.95,40,,3.84,percent of total billed charges,40% of total billed charges,1.56,4.15,
potassium chloride 10 mEq ER [FMC],2564540,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,35.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,46.48,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.68,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.112,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.12,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,60.46,36.276,,51.39,85,,41.112,Percent of total billed charges,85% of total billed charges,30.23,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.23,50,,8.128,percent of total billed charges,50% of total billed charges,19.32,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,19.32,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.97,38,,18.376,percent of total billed charges,38% of total billed charges,24.18,40,,3.84,percent of total billed charges,40% of total billed charges,19.32,51.39,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,15.6,9.36,,13.26,85,,10.608,Percent of total billed charges,85% of total billed charges,7.8,50,,4.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.8,50,,1.2,percent of total billed charges,50% of total billed charges,4.98,31.95,,5.696,percent of total billed charges,31.95% of total billed charges,4.98,31.95,,5.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.93,38,,4.744,percent of total billed charges,38% of total billed charges,6.24,40,,7.136,percent of total billed charges,40% of total billed charges,4.98,13.26,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,49.45,29.67,,42.03,85,,33.624,Percent of total billed charges,85% of total billed charges,24.73,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.73,50,,1.2,percent of total billed charges,50% of total billed charges,15.8,31.95,,5.696,percent of total billed charges,31.95% of total billed charges,15.8,31.95,,5.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.79,38,,15.032,percent of total billed charges,38% of total billed charges,19.78,40,,7.136,percent of total billed charges,40% of total billed charges,15.8,42.03,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,54.95,32.97,,46.71,85,,37.368,Percent of total billed charges,85% of total billed charges,27.48,50,,2.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.48,50,,4.8,percent of total billed charges,50% of total billed charges,17.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,17.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.88,38,,16.704,percent of total billed charges,38% of total billed charges,21.98,40,,0.96,percent of total billed charges,40% of total billed charges,17.56,46.71,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,27.31,16.386,,23.21,85,,18.568,Percent of total billed charges,85% of total billed charges,13.66,50,,9.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.66,50,,4.8,percent of total billed charges,50% of total billed charges,8.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,8.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.38,38,,8.304,percent of total billed charges,38% of total billed charges,10.92,40,,0.96,percent of total billed charges,40% of total billed charges,8.73,23.21,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,31.41,18.846,,26.7,85,,21.36,Percent of total billed charges,85% of total billed charges,15.71,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.71,50,,4.8,percent of total billed charges,50% of total billed charges,10.04,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,10.04,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.94,38,,9.552,percent of total billed charges,38% of total billed charges,12.56,40,,4.16,percent of total billed charges,40% of total billed charges,10.04,26.7,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,74.15,44.49,,63.03,85,,50.424,Percent of total billed charges,85% of total billed charges,37.08,50,,22.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.08,50,,4.8,percent of total billed charges,50% of total billed charges,23.69,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,23.69,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.18,38,,22.544,percent of total billed charges,38% of total billed charges,29.66,40,,4.16,percent of total billed charges,40% of total billed charges,23.69,63.03,
potassium chloride 20 mEq/15 mL Oral Liq [FMC],2564573,CDM,250,RC,,,OUTPATIENT,15,ML,48.22,28.932,,40.99,85,,32.792,Percent of total billed charges,85% of total billed charges,24.11,50,,33.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.11,50,,4.8,percent of total billed charges,50% of total billed charges,15.41,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,15.41,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.32,38,,14.656,percent of total billed charges,38% of total billed charges,19.29,40,,0.96,percent of total billed charges,40% of total billed charges,15.41,40.99,
potassium chloride 20 mEq/100 mL IV Sol [FMC],2564581,CDM,250,RC,J3480,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.136,percent of total billed charges,35.15% of total billed charges,447.3,31.95,,3.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.928,percent of total billed charges,31.95% of total billed charges,0.16,447.3,
potassium chloride 20 mEq/100 mL IV Sol [FMC],2564581,CDM,250,RC,J3480,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,9.72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.536,percent of total billed charges,35.15% of total billed charges,453.69,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,0.16,453.69,
potassium chloride 20 mEq/100 mL IV Sol [FMC],2564581,CDM,250,RC,J3480,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.536,percent of total billed charges,35.15% of total billed charges,456.25,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,0.16,456.25,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.952,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.192,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3.02,1.812,,2.57,85,,2.056,Percent of total billed charges,85% of total billed charges,1.51,50,,6.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.51,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.15,38,,0.92,percent of total billed charges,38% of total billed charges,1.21,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.57,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.736,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,26.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,30.488,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.056,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.32,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.656,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.872,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.192,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,13.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.344,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.68,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 20 mEq ER Tab [FMC],2564599,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,15.344,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.168,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 2 mEq/mL MDV Sol [FMC],2564607,CDM,250,RC,J3480,HCPCS,OUTPATIENT,20,ML,17.89,10.734,,15.21,85,,12.168,Percent of total billed charges,85% of total billed charges,0.16,136.6,,19.576,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,2.2,fee schedule,136.60% of BCBS custom fee schedule,6.29,35.15,,0.92,percent of total billed charges,35.15% of total billed charges,467.75,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.8,38,,5.44,percent of total billed charges,38% of total billed charges,5.72,31.95,,1.152,percent of total billed charges,31.95% of total billed charges,0.16,467.75,
potassium chloride 2 mEq/mL MDV Sol [FMC],2564607,CDM,250,RC,J3480,HCPCS,OUTPATIENT,20,ML,67.04,40.224,,56.98,85,,45.584,Percent of total billed charges,85% of total billed charges,0.16,136.6,,19.584,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,123.504,fee schedule,136.60% of BCBS custom fee schedule,23.56,35.15,,0.92,percent of total billed charges,35.15% of total billed charges,469.67,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.48,38,,20.384,percent of total billed charges,38% of total billed charges,21.42,31.95,,1.152,percent of total billed charges,31.95% of total billed charges,0.16,469.67,
potassium chloride 2 mEq/mL MDV Sol [FMC],2564607,CDM,250,RC,J3480,HCPCS,OUTPATIENT,20,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.16,136.6,,421.488,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,31.696,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.632,percent of total billed charges,35.15% of total billed charges,473.5,31.95,,4.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,5.8,percent of total billed charges,31.95% of total billed charges,0.16,473.5,
potassium gluconate 90mg Tab [FMC],2564615,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,9.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,62.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.576,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.728,percent of total billed charges,40% of total billed charges,0.96,2.55,
predniSONE 10 mg Tab [FMC],2564680,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,10.224,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,20.48,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,4.632,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,4.632,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,5.8,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
predniSONE 10 mg Tab [FMC],2564680,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,9.472,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,84.032,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
predniSONE 10 mg Tab [FMC],2564680,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,12.896,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,3.312,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
predniSONE 10 mg Tab [FMC],2564680,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,4.904,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,2.296,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,4.696,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,4.696,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,5.88,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
predniSONE 10 mg Tab [FMC],2564680,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,95.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,1.968,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,3.04,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,3.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,3.808,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
predniSONE 1 mg Tab [FMC],2564706,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,91.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,5.8,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,1.936,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,1.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,2.424,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
predniSONE 1 mg Tab [FMC],2564706,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,65.52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,5.856,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
predniSONE 1 mg Tab [FMC],2564706,CDM,250,RC,J7512,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,3.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,7.312,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.01,2.55,
prednisoLONE Ophth acetate 1% Susp [FMC],2564755,CDM,250,RC,,,OUTPATIENT,5,EA,253.73,152.238,,215.67,85,,172.536,Percent of total billed charges,85% of total billed charges,126.87,50,,3.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,126.87,50,,6.168,percent of total billed charges,50% of total billed charges,81.07,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,81.07,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,96.42,38,,77.136,percent of total billed charges,38% of total billed charges,101.49,40,,0.96,percent of total billed charges,40% of total billed charges,81.07,215.67,
prednisoLONE Ophth acetate 1% Susp [FMC],2564755,CDM,250,RC,,,OUTPATIENT,5,EA,179.79,107.874,,152.82,85,,122.256,Percent of total billed charges,85% of total billed charges,89.9,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,89.9,50,,13.064,percent of total billed charges,50% of total billed charges,57.44,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,57.44,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.32,38,,54.656,percent of total billed charges,38% of total billed charges,71.92,40,,0.96,percent of total billed charges,40% of total billed charges,57.44,152.82,
prednisoLONE sodium phosphate 15 mg/5 mL Oral Liq [FMC],2564763,CDM,250,RC,J7510,HCPCS,OUTPATIENT,5,ML,5.11,3.066,,4.34,85,,3.472,Percent of total billed charges,85% of total billed charges,0.36,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.36,136.6,,7.88,fee schedule,136.60% of BCBS custom fee schedule,1.8,35.15,,9.344,percent of total billed charges,35.15% of total billed charges,479.25,31.95,,9.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.94,38,,1.552,percent of total billed charges,38% of total billed charges,1.63,31.95,,11.696,percent of total billed charges,31.95% of total billed charges,0.36,479.25,
prednisoLONE sodium phosphate 15 mg/5 mL Oral Liq [FMC],2564763,CDM,250,RC,J7510,HCPCS,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.36,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.36,136.6,,13.656,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,20.872,percent of total billed charges,35.15% of total billed charges,479.25,31.95,,20.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,26.128,percent of total billed charges,31.95% of total billed charges,0.36,479.25,
preparation H oint hemorrhoidal 0.25% 28 gm [FMC],2564854,CDM,250,RC,,,OUTPATIENT,28,EA,20.44,12.264,,17.37,85,,13.896,Percent of total billed charges,85% of total billed charges,10.22,50,,4.616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.22,50,,10.568,percent of total billed charges,50% of total billed charges,6.53,31.95,,25.752,percent of total billed charges,31.95% of total billed charges,6.53,31.95,,25.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.77,38,,6.216,percent of total billed charges,38% of total billed charges,8.18,40,,32.24,percent of total billed charges,40% of total billed charges,6.53,17.37,
preparation H oint hemorrhoidal 0.25% 28 gm [FMC],2564854,CDM,250,RC,,,OUTPATIENT,28,EA,20.44,12.264,,17.37,85,,13.896,Percent of total billed charges,85% of total billed charges,10.22,50,,13.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.22,50,,9.36,percent of total billed charges,50% of total billed charges,6.53,31.95,,14.792,percent of total billed charges,31.95% of total billed charges,6.53,31.95,,14.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.77,38,,6.216,percent of total billed charges,38% of total billed charges,8.18,40,,18.52,percent of total billed charges,40% of total billed charges,6.53,17.37,
imipenem-cilastatin 500 mg Inj [FMC],2564920,CDM,250,RC,J0743,HCPCS,OUTPATIENT,1,EA,127.34,76.404,,108.24,85,,86.592,Percent of total billed charges,85% of total billed charges,11.91,136.6,,14.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.91,136.6,,9.168,fee schedule,136.60% of BCBS custom fee schedule,44.76,35.15,,149.528,percent of total billed charges,35.15% of total billed charges,479.25,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.39,38,,38.712,percent of total billed charges,38% of total billed charges,40.69,31.95,,187.2,percent of total billed charges,31.95% of total billed charges,11.91,479.25,
imipenem-cilastatin 500 mg Inj [FMC],2564920,CDM,250,RC,J0743,HCPCS,OUTPATIENT,1,EA,97.5,58.5,,82.88,85,,66.304,Percent of total billed charges,85% of total billed charges,11.91,136.6,,14.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.91,136.6,,17.944,fee schedule,136.60% of BCBS custom fee schedule,34.27,35.15,,13.056,percent of total billed charges,35.15% of total billed charges,480.53,31.95,,13.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.05,38,,29.64,percent of total billed charges,38% of total billed charges,31.15,31.95,,16.352,percent of total billed charges,31.95% of total billed charges,11.91,480.53,
imipenem-cilastatin 500 mg Inj [FMC],2564920,CDM,250,RC,J0743,HCPCS,OUTPATIENT,1,EA,97.5,58.5,,82.88,85,,66.304,Percent of total billed charges,85% of total billed charges,11.91,136.6,,28.08,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.91,136.6,,9.608,fee schedule,136.60% of BCBS custom fee schedule,34.27,35.15,,21.72,percent of total billed charges,35.15% of total billed charges,495.86,31.95,,21.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.05,38,,29.64,percent of total billed charges,38% of total billed charges,31.15,31.95,,27.192,percent of total billed charges,31.95% of total billed charges,11.91,495.86,
imipenem-cilastatin 500 mg-500 mg REC,2564920,CDM,250,RC,J0743,HCPCS,OUTPATIENT,1,EA,106.67,64.002,,90.67,85,,72.536,Percent of total billed charges,85% of total billed charges,11.91,136.6,,30.088,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.91,136.6,,16.12,fee schedule,136.60% of BCBS custom fee schedule,37.49,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,500.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.53,38,,32.424,percent of total billed charges,38% of total billed charges,34.08,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,11.91,500.02,
primidone 50 mg Tab [FMC],2564953,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,43.232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.176,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
primidone 50 mg Tab [FMC],2564953,CDM,250,RC,,,OUTPATIENT,1,EA,3.17,1.902,,2.69,85,,2.152,Percent of total billed charges,85% of total billed charges,1.59,50,,83.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.59,50,,17.176,percent of total billed charges,50% of total billed charges,1.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.2,38,,0.96,percent of total billed charges,38% of total billed charges,1.27,40,,0.96,percent of total billed charges,40% of total billed charges,1.01,2.69,
primidone 50 mg Tab [FMC],2564953,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,87.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.688,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.624,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.656,percent of total billed charges,40% of total billed charges,0.96,2.55,
primidone 50 mg Tab [FMC],2564953,CDM,250,RC,,,OUTPATIENT,1,EA,3.1,1.86,,2.64,85,,2.112,Percent of total billed charges,85% of total billed charges,1.55,50,,87.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.55,50,,1.2,percent of total billed charges,50% of total billed charges,0.99,31.95,,6.824,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.18,38,,0.944,percent of total billed charges,38% of total billed charges,1.24,40,,6.208,percent of total billed charges,40% of total billed charges,0.99,2.64,
lisinopril 10 mg Tab [FMC],2564961,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.6,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6,percent of total billed charges,40% of total billed charges,0.96,2.55,
lisinopril 10 mg Tab [FMC],2564961,CDM,250,RC,,,OUTPATIENT,1,EA,3.16,1.896,,2.69,85,,2.152,Percent of total billed charges,85% of total billed charges,1.58,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.58,50,,6.576,percent of total billed charges,50% of total billed charges,1.01,31.95,,7.224,percent of total billed charges,31.95% of total billed charges,1.01,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.2,38,,0.96,percent of total billed charges,38% of total billed charges,1.26,40,,6.56,percent of total billed charges,40% of total billed charges,1.01,2.69,
lisinopril 10 mg Tab [FMC],2564961,CDM,250,RC,,,OUTPATIENT,1,EA,3.23,1.938,,2.75,85,,2.2,Percent of total billed charges,85% of total billed charges,1.62,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.62,50,,6.424,percent of total billed charges,50% of total billed charges,1.03,31.95,,56.32,percent of total billed charges,31.95% of total billed charges,1.03,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.23,38,,0.984,percent of total billed charges,38% of total billed charges,1.29,40,,51.192,percent of total billed charges,40% of total billed charges,1.03,2.75,
lisinopril 10 mg Tab [FMC],2564961,CDM,250,RC,,,OUTPATIENT,1,EA,4.02,2.412,,3.42,85,,2.736,Percent of total billed charges,85% of total billed charges,2.01,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.01,50,,6.424,percent of total billed charges,50% of total billed charges,1.28,31.95,,91.144,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.53,38,,1.224,percent of total billed charges,38% of total billed charges,1.61,40,,82.848,percent of total billed charges,40% of total billed charges,1.28,3.42,
lisinopril 10 mg Tab [FMC],2564961,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.472,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
lisinopril 10 mg Tab [FMC],2564961,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.472,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.128,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.664,percent of total billed charges,40% of total billed charges,0.96,2.55,
acidophilus Tab [FMC],2565067,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.48,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.168,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.712,percent of total billed charges,40% of total billed charges,0.96,2.55,
acidophilus Tab [FMC],2565067,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.928,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.416,percent of total billed charges,40% of total billed charges,0.96,2.55,
prochlorperazine 25 mg Supp [FMC],2565091,CDM,250,RC,,,OUTPATIENT,1,EA,43.54,26.124,,37.01,85,,29.608,Percent of total billed charges,85% of total billed charges,21.77,50,,20.608,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.77,50,,3.272,percent of total billed charges,50% of total billed charges,13.91,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,13.91,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.55,38,,13.24,percent of total billed charges,38% of total billed charges,17.42,40,,1.392,percent of total billed charges,40% of total billed charges,13.91,37.01,
prochlorperazine 25 mg Supp [FMC],2565091,CDM,250,RC,,,OUTPATIENT,1,EA,40.89,24.534,,34.76,85,,27.808,Percent of total billed charges,85% of total billed charges,20.45,50,,19.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.45,50,,10.12,percent of total billed charges,50% of total billed charges,13.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.06,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.54,38,,12.432,percent of total billed charges,38% of total billed charges,16.36,40,,0.96,percent of total billed charges,40% of total billed charges,13.06,34.76,
hydrocortisone-pramoxine Rectal Foam [FMC],2565190,CDM,250,RC,,,OUTPATIENT,10,EA,687.57,412.542,,584.43,85,,467.544,Percent of total billed charges,85% of total billed charges,343.79,50,,3.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,343.79,50,,1.928,percent of total billed charges,50% of total billed charges,219.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,219.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,261.28,38,,209.024,percent of total billed charges,38% of total billed charges,275.03,40,,0.96,percent of total billed charges,40% of total billed charges,219.68,584.43,
pramoxine topical 1% Foam 15 gm [FMC],2565216,CDM,250,RC,,,OUTPATIENT,15,EA,146.58,87.948,,124.59,85,,99.672,Percent of total billed charges,85% of total billed charges,73.29,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.29,50,,1.928,percent of total billed charges,50% of total billed charges,46.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,46.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.7,38,,44.56,percent of total billed charges,38% of total billed charges,58.63,40,,0.96,percent of total billed charges,40% of total billed charges,46.83,124.59,
promethazine 25 mg/mL Inj Sol [FMC],2565232,CDM,250,RC,J2550,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,5.23,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.23,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,3.83,10.2,
promethazine 25 mg/mL Inj Sol [FMC],2565232,CDM,250,RC,J2550,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,5.23,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.23,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,53.952,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,53.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,67.552,Fee Schedule,31.95% of LA custom fee schedule,3.83,10.2,
promethazine 25 mg/mL Inj Sol [FMC],2565232,CDM,250,RC,J2550,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,5.23,136.6,,164.712,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.23,136.6,,5.728,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,52.824,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,52.824,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,66.136,Fee Schedule,31.95% of LA custom fee schedule,3.83,10.2,
promethazine 25 mg/mL Inj Sol [FMC],2565232,CDM,250,RC,J2550,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,5.23,136.6,,143.224,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.23,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,12.56,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,12.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,15.728,Fee Schedule,31.95% of LA custom fee schedule,3.83,10.2,
promethazine 25 mg/mL Inj Sol [FMC],2565232,CDM,250,RC,J2550,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,5.23,136.6,,351.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.23,136.6,,8.616,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,12.88,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,12.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,16.12,Fee Schedule,31.95% of LA custom fee schedule,3.83,10.2,
promethazine 25 mg Tab [FMC],2565240,CDM,250,RC,,,OUTPATIENT,1,EA,3.09,1.854,,2.63,85,,2.104,Percent of total billed charges,85% of total billed charges,1.55,50,,351.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.55,50,,3.528,percent of total billed charges,50% of total billed charges,0.99,31.95,,13.36,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,13.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.17,38,,0.936,percent of total billed charges,38% of total billed charges,1.24,40,,16.728,percent of total billed charges,40% of total billed charges,0.99,2.63,
promethazine 25 mg Tab [FMC],2565240,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,729.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.728,percent of total billed charges,40% of total billed charges,0.96,2.55,
promethazine 6.25 mg/5 mL 473ml Syr [FMC],2565265,CDM,250,RC,Q0169,HCPCS,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.33,136.6,,144.968,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.33,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,1.712,percent of total billed charges,35.15% of total billed charges,500.02,31.95,,1.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,2.144,percent of total billed charges,31.95% of total billed charges,0.33,500.02,
promethazine 6.25 mg/5 mL 473ml Syr [FMC],2565265,CDM,250,RC,Q0169,HCPCS,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.33,136.6,,17.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.33,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,1.384,percent of total billed charges,35.15% of total billed charges,504.81,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,1.728,percent of total billed charges,31.95% of total billed charges,0.33,504.81,
promethazine 6.25 mg/5 mL 473ml Syr [FMC],2565265,CDM,250,RC,Q0169,HCPCS,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.33,136.6,,194.04,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.33,136.6,,2.568,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,518.55,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.33,518.55,
promethazine 6.25 mg/5 mL 473ml Syr [FMC],2565265,CDM,250,RC,Q0169,HCPCS,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.33,136.6,,237.904,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.33,136.6,,2.24,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.33,527.18,
propranolol 10 mg Tab [FMC],2565299,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,238.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.856,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 10 mg Tab [FMC],2565299,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,32.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.184,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 10 mg Tab [FMC],2565299,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,11.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.976,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 10 mg Tab [FMC],2565299,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,17.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,12.504,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,12.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,15.648,percent of total billed charges,40% of total billed charges,0.96,2.55,
propylthiouracil 50 mg Tab [FMC],2565323,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.976,percent of total billed charges,50% of total billed charges,0.96,31.95,,46.224,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,46.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,57.872,percent of total billed charges,40% of total billed charges,0.96,2.55,
finasteride 5 mg Tab [FMC],2565349,CDM,250,RC,S0138,HCPCS,OUTPATIENT,1,EA,10.12,6.072,,8.6,85,,6.88,Percent of total billed charges,85% of total billed charges,4.06,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.06,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,3.56,35.15,,47.976,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,47.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.85,38,,3.08,percent of total billed charges,38% of total billed charges,3.23,31.95,,60.064,percent of total billed charges,31.95% of total billed charges,3.23,527.18,
finasteride 5 mg Tab [FMC],2565349,CDM,250,RC,S0138,HCPCS,OUTPATIENT,1,EA,10.17,6.102,,8.64,85,,6.912,Percent of total billed charges,85% of total billed charges,4.06,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.06,136.6,,2.032,fee schedule,136.60% of BCBS custom fee schedule,3.57,35.15,,50.672,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,50.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.86,38,,3.088,percent of total billed charges,38% of total billed charges,3.25,31.95,,63.44,percent of total billed charges,31.95% of total billed charges,3.25,527.18,
finasteride 5 mg Tab [FMC],2565349,CDM,250,RC,S0138,HCPCS,OUTPATIENT,1,EA,10.16,6.096,,8.64,85,,6.912,Percent of total billed charges,85% of total billed charges,4.06,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.06,136.6,,11.232,fee schedule,136.60% of BCBS custom fee schedule,3.57,35.15,,1.888,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,1.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.86,38,,3.088,percent of total billed charges,38% of total billed charges,3.25,31.95,,2.368,percent of total billed charges,31.95% of total billed charges,3.25,527.18,
pantoprazole 40 mg IV Inj [FMC],2565364,CDM,250,RC,J2470,HCPCS,OUTPATIENT,1,EA,19.5,11.7,,16.58,85,,13.264,Percent of total billed charges,85% of total billed charges,9.75,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.75,50,,7.64,percent of total billed charges,50% of total billed charges,6.85,35.15,,0.992,percent of total billed charges,35.15% of total billed charges,529.73,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.41,38,,5.928,percent of total billed charges,38% of total billed charges,6.23,31.95,,1.24,percent of total billed charges,31.95% of total billed charges,6.23,529.73,
pantoprazole 40 mg IV Inj [FMC],2565364,CDM,250,RC,J2470,HCPCS,OUTPATIENT,1,EA,27.63,16.578,,23.49,85,,18.792,Percent of total billed charges,85% of total billed charges,13.82,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.82,50,,14.2,percent of total billed charges,50% of total billed charges,9.71,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,531.01,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.5,38,,8.4,percent of total billed charges,38% of total billed charges,8.83,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,8.83,531.01,
pantoprazole 40 mg IV Inj [FMC],2565364,CDM,250,RC,J2470,HCPCS,OUTPATIENT,1,EA,19.6,11.76,,16.66,85,,13.328,Percent of total billed charges,85% of total billed charges,9.8,50,,180.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.8,50,,17.744,percent of total billed charges,50% of total billed charges,6.89,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,533.57,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.45,38,,5.96,percent of total billed charges,38% of total billed charges,6.26,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,6.26,533.57,
pantoprazole 40 mg IV Inj [FMC],2565364,CDM,250,RC,J2470,HCPCS,OUTPATIENT,1,EA,19.8,11.88,,16.83,85,,13.464,Percent of total billed charges,85% of total billed charges,9.9,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.9,50,,15.216,percent of total billed charges,50% of total billed charges,6.96,35.15,,1,percent of total billed charges,35.15% of total billed charges,533.57,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.52,38,,6.016,percent of total billed charges,38% of total billed charges,6.33,31.95,,1.248,percent of total billed charges,31.95% of total billed charges,6.33,533.57,
pantoprazole 40 mg IV Inj [FMC],2565364,CDM,250,RC,J2470,HCPCS,OUTPATIENT,1,EA,27.63,16.578,,23.49,85,,18.792,Percent of total billed charges,85% of total billed charges,13.82,50,,45.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.82,50,,9.048,percent of total billed charges,50% of total billed charges,9.71,35.15,,0.832,percent of total billed charges,35.15% of total billed charges,541.87,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.5,38,,8.4,percent of total billed charges,38% of total billed charges,8.83,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,8.83,541.87,
pantoprazole 40 mg IV Inj [FMC],2565364,CDM,250,RC,J2470,HCPCS,OUTPATIENT,1,EA,19.79,11.874,,16.82,85,,13.456,Percent of total billed charges,85% of total billed charges,9.9,50,,45.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.9,50,,1.552,percent of total billed charges,50% of total billed charges,6.96,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,550.18,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.52,38,,6.016,percent of total billed charges,38% of total billed charges,6.32,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,6.32,550.18,
pantoprazole 40 mg IV Inj [FMC],2565364,CDM,250,RC,J2470,HCPCS,OUTPATIENT,1,EA,16.25,9.75,,13.81,85,,11.048,Percent of total billed charges,85% of total billed charges,8.13,50,,40.728,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.13,50,,1.552,percent of total billed charges,50% of total billed charges,5.71,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,568.71,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.18,38,,4.944,percent of total billed charges,38% of total billed charges,5.19,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,5.19,568.71,
pantoprazole 40 mg DR UD [FMC],2565372,CDM,250,RC,,,OUTPATIENT,1,EA,17.12,10.272,,14.55,85,,11.64,Percent of total billed charges,85% of total billed charges,8.56,50,,40.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.56,50,,2.632,percent of total billed charges,50% of total billed charges,5.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.51,38,,5.208,percent of total billed charges,38% of total billed charges,6.85,40,,0.96,percent of total billed charges,40% of total billed charges,5.47,14.55,
pantoprazole 40 mg DR UD [FMC],2565372,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,40.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.536,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
pantoprazole 40 mg DR UD [FMC],2565372,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,40.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.368,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
pantoprazole 40 mg DR UD [FMC],2565372,CDM,250,RC,,,OUTPATIENT,1,EA,13.28,7.968,,11.29,85,,9.032,Percent of total billed charges,85% of total billed charges,6.64,50,,32.824,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.64,50,,3.936,percent of total billed charges,50% of total billed charges,4.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.24,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.05,38,,4.04,percent of total billed charges,38% of total billed charges,5.31,40,,0.96,percent of total billed charges,40% of total billed charges,4.24,11.29,
pantoprazole 40 mg DR UD [FMC],2565372,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,23.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,67.528,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.448,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.808,percent of total billed charges,40% of total billed charges,0.96,2.55,
pantoprazole 40 mg DR UD [FMC],2565372,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.536,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,67.528,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.096,percent of total billed charges,40% of total billed charges,0.96,2.55,
pantoprazole 40 mg DR UD [FMC],2565372,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,25.352,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.096,percent of total billed charges,40% of total billed charges,0.96,2.55,
protamine 10 mg/mL Inj Sol [FMC],2565380,CDM,250,RC,J2720,HCPCS,OUTPATIENT,5,ML,52.49,31.494,,44.62,85,,35.696,Percent of total billed charges,85% of total billed charges,1.19,136.6,,4.736,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.19,136.6,,4.856,fee schedule,136.60% of BCBS custom fee schedule,18.45,35.15,,2.128,fee schedule,35.15% of LA custom fee schedule,16.77,31.95,,2.128,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.95,38,,15.96,percent of total billed charges,38% of total billed charges,16.77,31.95,,2.664,Fee Schedule,31.95% of LA custom fee schedule,1.19,44.62,
protamine 10 mg/mL Inj Sol [FMC],2565380,CDM,250,RC,J2720,HCPCS,OUTPATIENT,5,ML,35.1,21.06,,29.84,85,,23.872,Percent of total billed charges,85% of total billed charges,1.19,136.6,,4.232,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.19,136.6,,3.064,fee schedule,136.60% of BCBS custom fee schedule,12.34,35.15,,15.136,fee schedule,35.15% of LA custom fee schedule,11.21,31.95,,15.136,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.34,38,,10.672,percent of total billed charges,38% of total billed charges,11.21,31.95,,18.952,Fee Schedule,31.95% of LA custom fee schedule,1.19,29.84,
pralidoxime 1 g REC [FMC],2565398,CDM,250,RC,J2730,HCPCS,OUTPATIENT,1,EA,352.22,211.332,,299.39,85,,239.512,Percent of total billed charges,85% of total billed charges,127.91,136.6,,28.08,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,127.91,136.6,,39,fee schedule,136.60% of BCBS custom fee schedule,123.81,35.15,,12.016,percent of total billed charges,35.15% of total billed charges,571.27,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133.84,38,,107.072,percent of total billed charges,38% of total billed charges,112.53,31.95,,15.04,percent of total billed charges,31.95% of total billed charges,112.53,571.27,
pralidoxime 1 g REC [FMC],2565398,CDM,250,RC,J2730,HCPCS,OUTPATIENT,1,EA,338.13,202.878,,287.41,85,,229.928,Percent of total billed charges,85% of total billed charges,127.91,136.6,,6.608,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,127.91,136.6,,1.68,fee schedule,136.60% of BCBS custom fee schedule,118.85,35.15,,12.84,percent of total billed charges,35.15% of total billed charges,571.27,31.95,,12.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.49,38,,102.792,percent of total billed charges,38% of total billed charges,108.03,31.95,,16.08,percent of total billed charges,31.95% of total billed charges,108.03,571.27,
medroxyPROGESTERone 2.5 mg Tab [FMC],2565422,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.512,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
medroxyPROGESTERone 2.5 mg Tab [FMC],2565422,CDM,250,RC,,,OUTPATIENT,1,EA,10.21,6.126,,8.68,85,,6.944,Percent of total billed charges,85% of total billed charges,5.11,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.11,50,,1.2,percent of total billed charges,50% of total billed charges,3.26,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,3.26,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.88,38,,3.104,percent of total billed charges,38% of total billed charges,4.08,40,,1.28,percent of total billed charges,40% of total billed charges,3.26,8.68,
guaiFENesin 600 mg ER [FMC],2565547,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.488,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
guaiFENesin 600 mg ER [FMC],2565547,CDM,250,RC,,,OUTPATIENT,1,EA,3.26,1.956,,2.77,85,,2.216,Percent of total billed charges,85% of total billed charges,1.63,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.63,50,,5.488,percent of total billed charges,50% of total billed charges,1.04,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.04,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.24,38,,0.992,percent of total billed charges,38% of total billed charges,1.3,40,,1.28,percent of total billed charges,40% of total billed charges,1.04,2.77,
guaiFENesin 600 mg ER [FMC],2565547,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.48,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.672,percent of total billed charges,40% of total billed charges,0.96,2.55,
guaiFENesin 600 mg ER [FMC],2565547,CDM,250,RC,,,OUTPATIENT,1,EA,3.47,2.082,,2.95,85,,2.36,Percent of total billed charges,85% of total billed charges,1.74,50,,1.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.74,50,,5.48,percent of total billed charges,50% of total billed charges,1.11,31.95,,1.2,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,1.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.32,38,,1.056,percent of total billed charges,38% of total billed charges,1.39,40,,1.504,percent of total billed charges,40% of total billed charges,1.11,2.95,
ocular lubricant Oint [FMC],2565695,CDM,250,RC,,,OUTPATIENT,3.5,EA,23.33,13.998,,19.83,85,,15.864,Percent of total billed charges,85% of total billed charges,11.67,50,,45.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.67,50,,10.016,percent of total billed charges,50% of total billed charges,7.45,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,7.45,31.95,,1.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.87,38,,7.096,percent of total billed charges,38% of total billed charges,9.33,40,,1.664,percent of total billed charges,40% of total billed charges,7.45,19.83,
ocular lubricant Oint [FMC],2565695,CDM,250,RC,,,OUTPATIENT,3.5,EA,12.61,7.566,,10.72,85,,8.576,Percent of total billed charges,85% of total billed charges,6.31,50,,48.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.31,50,,7.704,percent of total billed charges,50% of total billed charges,4.03,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,4.03,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.79,38,,3.832,percent of total billed charges,38% of total billed charges,5.04,40,,1.672,percent of total billed charges,40% of total billed charges,4.03,10.72,
ocular lubricant Oint [FMC],2565695,CDM,250,RC,,,OUTPATIENT,3.5,EA,16.12,9.672,,13.7,85,,10.96,Percent of total billed charges,85% of total billed charges,8.06,50,,13.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.06,50,,4.8,percent of total billed charges,50% of total billed charges,5.15,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,5.15,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.13,38,,4.904,percent of total billed charges,38% of total billed charges,6.45,40,,1.672,percent of total billed charges,40% of total billed charges,5.15,13.7,
ocular lubricant Oint [FMC],2565695,CDM,250,RC,,,OUTPATIENT,3.5,EA,38.32,22.992,,32.57,85,,26.056,Percent of total billed charges,85% of total billed charges,19.16,50,,12.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.16,50,,10.208,percent of total billed charges,50% of total billed charges,12.24,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,12.24,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.56,38,,11.648,percent of total billed charges,38% of total billed charges,15.33,40,,1.672,percent of total billed charges,40% of total billed charges,12.24,32.57,
ocular lubricant Oint [FMC],2565695,CDM,250,RC,,,OUTPATIENT,3.5,EA,27.89,16.734,,23.71,85,,18.968,Percent of total billed charges,85% of total billed charges,13.95,50,,86.664,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.95,50,,10.616,percent of total billed charges,50% of total billed charges,8.91,31.95,,1.2,percent of total billed charges,31.95% of total billed charges,8.91,31.95,,1.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.6,38,,8.48,percent of total billed charges,38% of total billed charges,11.16,40,,1.504,percent of total billed charges,40% of total billed charges,8.91,23.71,
mirtazapine 15 mg Tab [FMC],2565745,CDM,250,RC,,,OUTPATIENT,1,EA,11.03,6.618,,9.38,85,,7.504,Percent of total billed charges,85% of total billed charges,5.52,50,,86.664,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.52,50,,10.616,percent of total billed charges,50% of total billed charges,3.52,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,3.52,31.95,,1.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.19,38,,3.352,percent of total billed charges,38% of total billed charges,4.41,40,,1.672,percent of total billed charges,40% of total billed charges,3.52,9.38,
mirtazapine 15 mg Tab [FMC],2565745,CDM,250,RC,,,OUTPATIENT,1,EA,9.29,5.574,,7.9,85,,6.32,Percent of total billed charges,85% of total billed charges,4.65,50,,67.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.65,50,,2.504,percent of total billed charges,50% of total billed charges,2.97,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,2.97,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.53,38,,2.824,percent of total billed charges,38% of total billed charges,3.72,40,,1.92,percent of total billed charges,40% of total billed charges,2.97,7.9,
rOPINIRole 1 mg Tab [FMC],2565802,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,69.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.416,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
rOPINIRole 1 mg Tab [FMC],2565802,CDM,250,RC,,,OUTPATIENT,1,EA,8.13,4.878,,6.91,85,,5.528,Percent of total billed charges,85% of total billed charges,4.07,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.07,50,,4.808,percent of total billed charges,50% of total billed charges,2.6,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,2.6,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.09,38,,2.472,percent of total billed charges,38% of total billed charges,3.25,40,,1.976,percent of total billed charges,40% of total billed charges,2.6,6.91,
rOPINIRole 1 mg Tab [FMC],2565802,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.696,percent of total billed charges,50% of total billed charges,0.96,31.95,,11.616,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,11.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,14.544,percent of total billed charges,40% of total billed charges,0.96,2.55,
cycloSPORINE Ophth 0.05% Emul [FMC],2565836,CDM,250,RC,,,OUTPATIENT,1,EA,41.96,25.176,,35.67,85,,28.536,Percent of total billed charges,85% of total billed charges,20.98,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.98,50,,2.304,percent of total billed charges,50% of total billed charges,13.41,31.95,,2.768,percent of total billed charges,31.95% of total billed charges,13.41,31.95,,2.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.94,38,,12.752,percent of total billed charges,38% of total billed charges,16.78,40,,3.464,percent of total billed charges,40% of total billed charges,13.41,35.67,
cycloSPORINE Ophth 0.05% Emul [FMC],2565836,CDM,250,RC,,,OUTPATIENT,1,EA,39.87,23.922,,33.89,85,,27.112,Percent of total billed charges,85% of total billed charges,19.94,50,,3.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.94,50,,4.68,percent of total billed charges,50% of total billed charges,12.74,31.95,,2.944,percent of total billed charges,31.95% of total billed charges,12.74,31.95,,2.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.15,38,,12.12,percent of total billed charges,38% of total billed charges,15.95,40,,3.688,percent of total billed charges,40% of total billed charges,12.74,33.89,
rifampin 150 mg Cap [FMC],2565893,CDM,250,RC,,,OUTPATIENT,1,EA,4.74,2.844,,4.03,85,,3.224,Percent of total billed charges,85% of total billed charges,2.37,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.37,50,,1.2,percent of total billed charges,50% of total billed charges,1.51,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.51,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.8,38,,1.44,percent of total billed charges,38% of total billed charges,1.9,40,,0.96,percent of total billed charges,40% of total billed charges,1.51,4.03,
rifampin 150 mg Cap [FMC],2565893,CDM,250,RC,,,OUTPATIENT,1,EA,5.12,3.072,,4.35,85,,3.48,Percent of total billed charges,85% of total billed charges,2.56,50,,3.456,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.56,50,,3.752,percent of total billed charges,50% of total billed charges,1.64,31.95,,9.752,percent of total billed charges,31.95% of total billed charges,1.64,31.95,,487.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.95,38,,1.56,percent of total billed charges,38% of total billed charges,2.05,40,,8.864,percent of total billed charges,40% of total billed charges,1.64,4.35,
rifampin 150 mg Cap [FMC],2565893,CDM,250,RC,,,OUTPATIENT,1,EA,6.46,3.876,,5.49,85,,4.392,Percent of total billed charges,85% of total billed charges,3.23,50,,73.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.23,50,,2.4,percent of total billed charges,50% of total billed charges,2.06,31.95,,10.912,percent of total billed charges,31.95% of total billed charges,2.06,31.95,,495.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.45,38,,1.96,percent of total billed charges,38% of total billed charges,2.58,40,,9.92,percent of total billed charges,40% of total billed charges,2.06,5.49,
risperiDONE 0.25 mg Tab [FMC],2565901,CDM,250,RC,,,OUTPATIENT,1,EA,11.64,6.984,,9.89,85,,7.912,Percent of total billed charges,85% of total billed charges,5.82,50,,68.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.82,50,,2.4,percent of total billed charges,50% of total billed charges,3.72,31.95,,11.368,percent of total billed charges,31.95% of total billed charges,3.72,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.42,38,,3.536,percent of total billed charges,38% of total billed charges,4.66,40,,10.328,percent of total billed charges,40% of total billed charges,3.72,9.89,
risperiDONE 0.25 mg Tab [FMC],2565901,CDM,250,RC,,,OUTPATIENT,1,EA,6.56,3.936,,5.58,85,,4.464,Percent of total billed charges,85% of total billed charges,3.28,50,,18.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.28,50,,1.2,percent of total billed charges,50% of total billed charges,2.1,31.95,,10.912,percent of total billed charges,31.95% of total billed charges,2.1,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.49,38,,1.992,percent of total billed charges,38% of total billed charges,2.62,40,,9.92,percent of total billed charges,40% of total billed charges,2.1,5.58,
risperiDONE 0.25 mg Tab [FMC],2565901,CDM,250,RC,,,OUTPATIENT,1,EA,12.68,7.608,,10.78,85,,8.624,Percent of total billed charges,85% of total billed charges,6.34,50,,9.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.34,50,,1.312,percent of total billed charges,50% of total billed charges,4.05,31.95,,10.912,percent of total billed charges,31.95% of total billed charges,4.05,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.82,38,,3.856,percent of total billed charges,38% of total billed charges,5.07,40,,9.92,percent of total billed charges,40% of total billed charges,4.05,10.78,
risperiDONE 0.25 mg Tab [FMC],2565901,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,16.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.784,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
risperiDONE 1 mg Tab [FMC],2565927,CDM,250,RC,,,OUTPATIENT,1,EA,14.83,8.898,,12.61,85,,10.088,Percent of total billed charges,85% of total billed charges,7.42,50,,16.736,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.42,50,,6.792,percent of total billed charges,50% of total billed charges,4.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.64,38,,4.512,percent of total billed charges,38% of total billed charges,5.93,40,,0.96,percent of total billed charges,40% of total billed charges,4.74,12.61,
risperiDONE 1 mg Tab [FMC],2565927,CDM,250,RC,,,OUTPATIENT,1,EA,7.65,4.59,,6.5,85,,5.2,Percent of total billed charges,85% of total billed charges,3.83,50,,16.736,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.83,50,,6.208,percent of total billed charges,50% of total billed charges,2.44,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.44,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.91,38,,2.328,percent of total billed charges,38% of total billed charges,3.06,40,,0.96,percent of total billed charges,40% of total billed charges,2.44,6.5,
risperiDONE 1 mg Tab [FMC],2565927,CDM,250,RC,,,OUTPATIENT,1,EA,14.76,8.856,,12.55,85,,10.04,Percent of total billed charges,85% of total billed charges,7.38,50,,19.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.38,50,,10.096,percent of total billed charges,50% of total billed charges,4.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.61,38,,4.488,percent of total billed charges,38% of total billed charges,5.9,40,,0.96,percent of total billed charges,40% of total billed charges,4.72,12.55,
methocarbamol 100 mg/mL Sol [FMC],2565943,CDM,250,RC,J2800,HCPCS,OUTPATIENT,10,ML,170.04,102.024,,144.53,85,,115.624,Percent of total billed charges,85% of total billed charges,9.12,136.6,,35.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.12,136.6,,6.792,fee schedule,136.60% of BCBS custom fee schedule,59.77,35.15,,137.752,percent of total billed charges,35.15% of total billed charges,571.27,31.95,,137.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.62,38,,51.696,percent of total billed charges,38% of total billed charges,54.33,31.95,,172.464,percent of total billed charges,31.95% of total billed charges,9.12,571.27,
methocarbamol 100 mg/mL Sol [FMC],2565943,CDM,250,RC,J2800,HCPCS,OUTPATIENT,10,ML,112.53,67.518,,95.65,85,,76.52,Percent of total billed charges,85% of total billed charges,9.12,136.6,,15.264,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.12,136.6,,6.056,fee schedule,136.60% of BCBS custom fee schedule,39.55,35.15,,12.464,percent of total billed charges,35.15% of total billed charges,571.27,31.95,,12.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.76,38,,34.208,percent of total billed charges,38% of total billed charges,35.95,31.95,,15.6,percent of total billed charges,31.95% of total billed charges,9.12,571.27,
methocarbamol 100 mg/mL Sol [FMC],2565943,CDM,250,RC,J2800,HCPCS,OUTPATIENT,10,ML,231.66,138.996,,196.91,85,,157.528,Percent of total billed charges,85% of total billed charges,9.12,136.6,,45.504,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.12,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,81.43,35.15,,2.976,percent of total billed charges,35.15% of total billed charges,571.27,31.95,,2.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.03,38,,70.424,percent of total billed charges,38% of total billed charges,74.02,31.95,,3.728,percent of total billed charges,31.95% of total billed charges,9.12,571.27,
methocarbamol 100 mg/mL Sol [FMC],2565943,CDM,250,RC,J2800,HCPCS,OUTPATIENT,10,ML,35.1,21.06,,29.84,85,,23.872,Percent of total billed charges,85% of total billed charges,9.12,136.6,,18.016,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.12,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,12.34,35.15,,40.496,percent of total billed charges,35.15% of total billed charges,573.5,31.95,,40.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.34,38,,10.672,percent of total billed charges,38% of total billed charges,11.21,31.95,,50.704,percent of total billed charges,31.95% of total billed charges,9.12,573.5,
glycopyrrolate 0.2 mg/mL Inj Sol [FMC],2565968,CDM,250,RC,J7642,HCPCS,OUTPATIENT,5,ML,223.36,134.016,,189.86,85,,151.888,Percent of total billed charges,85% of total billed charges,1.6,136.6,,18.136,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.6,136.6,,3.784,fee schedule,136.60% of BCBS custom fee schedule,78.51,35.15,,42.368,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,42.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,84.88,38,,67.904,percent of total billed charges,38% of total billed charges,71.36,31.95,,53.04,percent of total billed charges,31.95% of total billed charges,1.6,575.1,
glycopyrrolate 0.2 mg/mL Inj Sol [FMC],2565968,CDM,250,RC,J7642,HCPCS,OUTPATIENT,5,ML,178.75,107.25,,151.94,85,,121.552,Percent of total billed charges,85% of total billed charges,1.6,136.6,,3.248,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.6,136.6,,3.656,fee schedule,136.60% of BCBS custom fee schedule,62.83,35.15,,42.368,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,42.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,67.93,38,,54.344,percent of total billed charges,38% of total billed charges,57.11,31.95,,53.04,percent of total billed charges,31.95% of total billed charges,1.6,575.1,
glycopyrrolate 0.2 mg/mL Inj Sol [FMC],2565968,CDM,250,RC,J7642,HCPCS,OUTPATIENT,5,ML,106.05,63.63,,90.14,85,,72.112,Percent of total billed charges,85% of total billed charges,1.6,136.6,,5.136,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.6,136.6,,2.728,fee schedule,136.60% of BCBS custom fee schedule,37.28,35.15,,10.968,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.3,38,,32.24,percent of total billed charges,38% of total billed charges,33.88,31.95,,13.728,percent of total billed charges,31.95% of total billed charges,1.6,575.1,
glycopyrrolate 0.2 mg/mL Inj Sol [FMC],2565968,CDM,250,RC,J7642,HCPCS,OUTPATIENT,5,ML,144.43,86.658,,122.77,85,,98.216,Percent of total billed charges,85% of total billed charges,1.6,136.6,,59.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.6,136.6,,4.136,fee schedule,136.60% of BCBS custom fee schedule,50.77,35.15,,9.224,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,9.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.88,38,,43.904,percent of total billed charges,38% of total billed charges,46.15,31.95,,11.544,percent of total billed charges,31.95% of total billed charges,1.6,575.1,
guanFACINE 1 mg Tab [FMC],2565984,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.536,percent of total billed charges,50% of total billed charges,0.96,31.95,,16.352,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,16.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,20.464,percent of total billed charges,40% of total billed charges,0.96,2.55,
glycopyrrolate 1 mg Tab [FMC],2565984,CDM,250,RC,,,OUTPATIENT,1,EA,4.27,2.562,,3.63,85,,2.904,Percent of total billed charges,85% of total billed charges,2.14,50,,64.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.14,50,,4.144,percent of total billed charges,50% of total billed charges,1.36,31.95,,3833.168,percent of total billed charges,31.95% of total billed charges,1.36,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.62,38,,1.296,percent of total billed charges,38% of total billed charges,1.71,40,,3484.2,percent of total billed charges,40% of total billed charges,1.36,3.63,
glycopyrrolate 1 mg Tab [FMC],2565984,CDM,250,RC,,,OUTPATIENT,1,EA,4.21,2.526,,3.58,85,,2.864,Percent of total billed charges,85% of total billed charges,2.11,50,,45.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.11,50,,4.136,percent of total billed charges,50% of total billed charges,1.35,31.95,,12.096,percent of total billed charges,31.95% of total billed charges,1.35,31.95,,12.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.6,38,,1.28,percent of total billed charges,38% of total billed charges,1.68,40,,15.144,percent of total billed charges,40% of total billed charges,1.35,3.58,
glycopyrrolate 1 mg Tab [FMC],2565984,CDM,250,RC,,,OUTPATIENT,1,EA,4.06,2.436,,3.45,85,,2.76,Percent of total billed charges,85% of total billed charges,2.03,50,,1.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.03,50,,1.2,percent of total billed charges,50% of total billed charges,1.3,31.95,,28.232,percent of total billed charges,31.95% of total billed charges,1.3,31.95,,28.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.54,38,,1.232,percent of total billed charges,38% of total billed charges,1.62,40,,35.344,percent of total billed charges,40% of total billed charges,1.3,3.45,
glycopyrrolate 1 mg Tab [FMC],2565984,CDM,250,RC,,,OUTPATIENT,1,EA,4.22,2.532,,3.59,85,,2.872,Percent of total billed charges,85% of total billed charges,2.11,50,,1.848,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.11,50,,4.52,percent of total billed charges,50% of total billed charges,1.35,31.95,,5.192,percent of total billed charges,31.95% of total billed charges,1.35,31.95,,5.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.6,38,,1.28,percent of total billed charges,38% of total billed charges,1.69,40,,6.496,percent of total billed charges,40% of total billed charges,1.35,3.59,
calcitriol 0.25 mcg Oral Cap [FMC],2565992,CDM,250,RC,,,OUTPATIENT,1,EA,4.11,2.466,,3.49,85,,2.792,Percent of total billed charges,85% of total billed charges,2.06,50,,5307.84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.06,50,,10.992,percent of total billed charges,50% of total billed charges,1.31,31.95,,171.856,percent of total billed charges,31.95% of total billed charges,1.31,31.95,,171.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.56,38,,1.248,percent of total billed charges,38% of total billed charges,1.64,40,,215.152,percent of total billed charges,40% of total billed charges,1.31,3.49,
metOLazone 5 mg TabmetOLazone 5 mg Tab -  - Inpatient - FMC HOSP - Active - 00185-0055-01,2565992,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.992,percent of total billed charges,50% of total billed charges,0.96,31.95,,227.488,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,227.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,284.8,percent of total billed charges,40% of total billed charges,0.96,2.55,
metOLazone 5 mg TabmetOLazone 5 mg Tab -  - Inpatient - FMC HOSP - Active - 00185-0055-01 -  - Inpatient - FMC HOSP - Active - 30698-0143-01,2565992,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,182.648,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.784,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.24,percent of total billed charges,40% of total billed charges,0.96,2.55,
flumazenil 0.1 mg/mL IV Sol [FMC],2566040,CDM,250,RC,,,OUTPATIENT,5,ML,26.41,15.846,,22.45,85,,17.96,Percent of total billed charges,85% of total billed charges,13.21,50,,19.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.21,50,,182.648,percent of total billed charges,50% of total billed charges,8.44,31.95,,5.152,percent of total billed charges,31.95% of total billed charges,8.44,31.95,,5.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.04,38,,8.032,percent of total billed charges,38% of total billed charges,10.56,40,,6.448,percent of total billed charges,40% of total billed charges,8.44,22.45,
flumazenil 0.1 mg/mL IV Sol [FMC],2566040,CDM,250,RC,,,OUTPATIENT,5,ML,26.44,15.864,,22.47,85,,17.976,Percent of total billed charges,85% of total billed charges,13.22,50,,40.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.22,50,,15.456,percent of total billed charges,50% of total billed charges,8.45,31.95,,2.096,percent of total billed charges,31.95% of total billed charges,8.45,31.95,,2.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.05,38,,8.04,percent of total billed charges,38% of total billed charges,10.58,40,,2.624,percent of total billed charges,40% of total billed charges,8.45,22.47,
flumazenil 0.1 mg/mL IV Sol [FMC],2566040,CDM,250,RC,,,OUTPATIENT,5,ML,25.35,15.21,,21.55,85,,17.24,Percent of total billed charges,85% of total billed charges,12.68,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.68,50,,2.104,percent of total billed charges,50% of total billed charges,8.1,31.95,,1.744,percent of total billed charges,31.95% of total billed charges,8.1,31.95,,1.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.63,38,,7.704,percent of total billed charges,38% of total billed charges,10.14,40,,2.184,percent of total billed charges,40% of total billed charges,8.1,21.55,
propafenone 150 mg Tab [FMC],2566065,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.968,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.216,percent of total billed charges,40% of total billed charges,0.96,2.55,
propafenone 150 mg Tab [FMC],2566065,CDM,250,RC,,,OUTPATIENT,1,EA,3.05,1.83,,2.59,85,,2.072,Percent of total billed charges,85% of total billed charges,1.53,50,,5.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.53,50,,2.528,percent of total billed charges,50% of total billed charges,0.97,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,0.97,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.16,38,,0.928,percent of total billed charges,38% of total billed charges,1.22,40,,1.16,percent of total billed charges,40% of total billed charges,0.97,2.59,
propafenone 150 mg Tab [FMC],2566065,CDM,250,RC,,,OUTPATIENT,1,EA,5.32,3.192,,4.52,85,,3.616,Percent of total billed charges,85% of total billed charges,2.66,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.66,50,,1.6,percent of total billed charges,50% of total billed charges,1.7,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,1.7,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.02,38,,1.616,percent of total billed charges,38% of total billed charges,2.13,40,,1.288,percent of total billed charges,40% of total billed charges,1.7,4.52,
propafenone 150 mg Tab [FMC],2566065,CDM,250,RC,,,OUTPATIENT,1,EA,3.01,1.806,,2.56,85,,2.048,Percent of total billed charges,85% of total billed charges,1.51,50,,15.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.51,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.16,percent of total billed charges,40% of total billed charges,0.96,2.56,
propafenone 150 mg Tabpropafenone 150 mg Tab [FMC],2566065,CDM,250,RC,,,OUTPATIENT,1,EA,5.32,3.192,,4.52,85,,3.616,Percent of total billed charges,85% of total billed charges,2.66,50,,9.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.66,50,,35.704,percent of total billed charges,50% of total billed charges,1.7,31.95,,0.912,percent of total billed charges,31.95% of total billed charges,1.7,31.95,,0.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.02,38,,1.616,percent of total billed charges,38% of total billed charges,2.13,40,,1.144,percent of total billed charges,40% of total billed charges,1.7,4.52,
salsalate 500 mg Tab [FMC],2566107,CDM,250,RC,,,OUTPATIENT,1,EA,5.55,3.33,,4.72,85,,3.776,Percent of total billed charges,85% of total billed charges,2.78,50,,5.608,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.78,50,,28.536,percent of total billed charges,50% of total billed charges,1.77,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,1.77,31.95,,0.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.11,38,,1.688,percent of total billed charges,38% of total billed charges,2.22,40,,1.16,percent of total billed charges,40% of total billed charges,1.77,4.72,
salsalate 500 mg Tab [FMC],2566107,CDM,250,RC,,,OUTPATIENT,1,EA,8.12,4.872,,6.9,85,,5.52,Percent of total billed charges,85% of total billed charges,4.06,50,,51.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.06,50,,48.696,percent of total billed charges,50% of total billed charges,2.59,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,2.59,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.09,38,,2.472,percent of total billed charges,38% of total billed charges,3.25,40,,1.288,percent of total billed charges,40% of total billed charges,2.59,6.9,
salsalate 500 mg Tab [FMC],2566107,CDM,250,RC,,,OUTPATIENT,1,EA,6.17,3.702,,5.24,85,,4.192,Percent of total billed charges,85% of total billed charges,3.09,50,,51.408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.09,50,,49.336,percent of total billed charges,50% of total billed charges,1.97,31.95,,0.912,percent of total billed charges,31.95% of total billed charges,1.97,31.95,,0.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.34,38,,1.872,percent of total billed charges,38% of total billed charges,2.47,40,,1.144,percent of total billed charges,40% of total billed charges,1.97,5.24,
salsalate 500 mg Tab,2566107,CDM,250,RC,,,OUTPATIENT,1,EA,6.17,3.702,,5.24,85,,4.192,Percent of total billed charges,85% of total billed charges,3.09,50,,51.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.09,50,,36.4,percent of total billed charges,50% of total billed charges,1.97,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.97,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.34,38,,1.872,percent of total billed charges,38% of total billed charges,2.47,40,,1.28,percent of total billed charges,40% of total billed charges,1.97,5.24,
salsalate 500 mg Tab [FMC],2566107,CDM,250,RC,,,OUTPATIENT,1,EA,5.55,3.33,,4.72,85,,3.776,Percent of total billed charges,85% of total billed charges,2.78,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.78,50,,6.28,percent of total billed charges,50% of total billed charges,1.77,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.77,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.11,38,,1.688,percent of total billed charges,38% of total billed charges,2.22,40,,1.28,percent of total billed charges,40% of total billed charges,1.77,4.72,
salsalate 500 mg Tab [FMC],2566107,CDM,250,RC,,,OUTPATIENT,1,EA,6.34,3.804,,5.39,85,,4.312,Percent of total billed charges,85% of total billed charges,3.17,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.17,50,,6.28,percent of total billed charges,50% of total billed charges,2.03,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,2.03,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.41,38,,1.928,percent of total billed charges,38% of total billed charges,2.54,40,,1.28,percent of total billed charges,40% of total billed charges,2.03,5.39,
glycerin ADULT Supp [FMC],2566123,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.104,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.28,percent of total billed charges,40% of total billed charges,1.92,5.1,
glycerin ADULT Supp [FMC],2566123,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,5.368,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,1.6,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.28,percent of total billed charges,40% of total billed charges,1.92,5.1,
docusate-senna 50 mg-8.6 mg Tab [FMC],2566222,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.488,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate-senna 50 mg-8.6 mg Tab [FMC],2566222,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.488,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate-senna 50 mg-8.6 mg Tab [FMC],2566222,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.44,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate-senna 50 mg-8.6 mg Tab [FMC],2566222,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.392,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate-senna 50 mg-8.6 mg Tab [FMC],2566222,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate-senna 50 mg-8.6 mg Tab [FMC],2566222,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.024,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.976,percent of total billed charges,40% of total billed charges,0.96,2.55,
senna 8.6 mg Tab [FMC],2566230,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.16,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.704,percent of total billed charges,40% of total billed charges,0.96,2.55,
senna 8.6 mg Tab [FMC],2566230,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.464,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.504,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.976,percent of total billed charges,40% of total billed charges,0.96,2.55,
senna 8.6 mg Tab [FMC],2566230,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,19.048,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
senna 8.6 mg Tab [FMC],2566230,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,17.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,18.032,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
bupivacaine 0.25% preservative-free Sol [FMC],2566255,CDM,250,RC,,,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,1.2,percent of total billed charges,50% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,0.96,percent of total billed charges,40% of total billed charges,3.83,10.2,
bupivacaine 0.25% preservative-free Sol [FMC],2566255,CDM,250,RC,,,OUTPATIENT,10,ML,22.23,13.338,,18.9,85,,15.12,Percent of total billed charges,85% of total billed charges,11.12,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.12,50,,1.2,percent of total billed charges,50% of total billed charges,7.1,31.95,,0.896,percent of total billed charges,31.95% of total billed charges,7.1,31.95,,0.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.45,38,,6.76,percent of total billed charges,38% of total billed charges,8.89,40,,1.12,percent of total billed charges,40% of total billed charges,7.1,18.9,
bupivacaine 0.25% preservative-free Sol [FMC],2566255,CDM,250,RC,,,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,1.2,percent of total billed charges,50% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,0.96,percent of total billed charges,40% of total billed charges,3.83,10.2,
bupivacaine 0.25% preservative-free Sol [FMC],2566255,CDM,250,RC,,,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,7.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,1.2,percent of total billed charges,50% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,0.96,percent of total billed charges,40% of total billed charges,3.83,10.2,
QUEtiapine 100 mg Tab [FMC],2566313,CDM,250,RC,,,OUTPATIENT,1,EA,22.29,13.374,,18.95,85,,15.16,Percent of total billed charges,85% of total billed charges,11.15,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.15,50,,1.2,percent of total billed charges,50% of total billed charges,7.12,31.95,,0.896,percent of total billed charges,31.95% of total billed charges,7.12,31.95,,0.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.47,38,,6.776,percent of total billed charges,38% of total billed charges,8.92,40,,1.12,percent of total billed charges,40% of total billed charges,7.12,18.95,
QUEtiapine 100 mg Tab [FMC],2566313,CDM,250,RC,,,OUTPATIENT,1,EA,22.29,13.374,,18.95,85,,15.16,Percent of total billed charges,85% of total billed charges,11.15,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.15,50,,236.944,percent of total billed charges,50% of total billed charges,7.12,31.95,,4.84,percent of total billed charges,31.95% of total billed charges,7.12,31.95,,4.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.47,38,,6.776,percent of total billed charges,38% of total billed charges,8.92,40,,6.064,percent of total billed charges,40% of total billed charges,7.12,18.95,
QUEtiapine 100 mg Tab [FMC],2566313,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,213.008,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.64,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.808,percent of total billed charges,40% of total billed charges,0.96,2.55,
QUEtiapine 100 mg Tab [FMC],2566313,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,212.864,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.576,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.728,percent of total billed charges,40% of total billed charges,0.96,2.55,
QUEtiapine 25 mg Tab UD [FMC],2566321,CDM,250,RC,,,OUTPATIENT,1,EA,12.99,7.794,,11.04,85,,8.832,Percent of total billed charges,85% of total billed charges,6.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,213.24,percent of total billed charges,50% of total billed charges,4.15,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,2.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,3.952,percent of total billed charges,38% of total billed charges,5.2,40,,2.848,percent of total billed charges,40% of total billed charges,4.15,11.04,
QUEtiapine 25 mg Tab UD [FMC],2566321,CDM,250,RC,,,OUTPATIENT,1,EA,12.99,7.794,,11.04,85,,8.832,Percent of total billed charges,85% of total billed charges,6.5,50,,118.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,8.28,percent of total billed charges,50% of total billed charges,4.15,31.95,,2.648,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,2.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,3.952,percent of total billed charges,38% of total billed charges,5.2,40,,3.312,percent of total billed charges,40% of total billed charges,4.15,11.04,
QUEtiapine 25 mg Tab UD [FMC],2566321,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,97.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.656,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.824,percent of total billed charges,40% of total billed charges,0.96,2.55,
QUEtiapine 25 mg Tab UD [FMC],2566321,CDM,250,RC,,,OUTPATIENT,1,EA,12.28,7.368,,10.44,85,,8.352,Percent of total billed charges,85% of total billed charges,6.14,50,,84.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.14,50,,10.128,percent of total billed charges,50% of total billed charges,3.92,31.95,,66.944,percent of total billed charges,31.95% of total billed charges,3.92,31.95,,66.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.67,38,,3.736,percent of total billed charges,38% of total billed charges,4.91,40,,83.816,percent of total billed charges,40% of total billed charges,3.92,10.44,
silver nitrate Top Stick [FMC],2566347,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,70.192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,1.2,percent of total billed charges,50% of total billed charges,1.92,31.95,,68.976,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,68.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,86.352,percent of total billed charges,40% of total billed charges,1.92,5.1,
silver nitrate Top Stick [FMC],2566347,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,10.024,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,1.864,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.256,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.568,percent of total billed charges,40% of total billed charges,1.92,5.1,
carbidopa-levodopa 10 mg-100 mg Tab [FMC],2566362,CDM,250,RC,,,OUTPATIENT,1,EA,3.72,2.232,,3.16,85,,2.528,Percent of total billed charges,85% of total billed charges,1.86,50,,4563.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.86,50,,3.544,percent of total billed charges,50% of total billed charges,1.19,31.95,,1.264,percent of total billed charges,31.95% of total billed charges,1.19,31.95,,1.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.41,38,,1.128,percent of total billed charges,38% of total billed charges,1.49,40,,1.584,percent of total billed charges,40% of total billed charges,1.19,3.16,
carbidopa-levodopa 10 mg-100 mg Tab [FMC],2566362,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,77.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.56,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.192,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.496,percent of total billed charges,40% of total billed charges,0.96,2.55,
carbidopa-levodopa 10 mg-100 mg Tab [FMC],2566362,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.584,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.552,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.256,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.568,percent of total billed charges,40% of total billed charges,0.96,2.55,
carbidopa-levodopa 10 mg-100 mg Tab [FMC],2566362,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.216,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.392,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,11.76,percent of total billed charges,40% of total billed charges,0.96,2.55,
carbidopa-levodopa 25 mg-100 mg Tab [FMC],2566370,CDM,250,RC,,,OUTPATIENT,1,EA,4.12,2.472,,3.5,85,,2.8,Percent of total billed charges,85% of total billed charges,2.06,50,,60.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.06,50,,1.2,percent of total billed charges,50% of total billed charges,1.32,31.95,,8.856,percent of total billed charges,31.95% of total billed charges,1.32,31.95,,8.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.57,38,,1.256,percent of total billed charges,38% of total billed charges,1.65,40,,11.088,percent of total billed charges,40% of total billed charges,1.32,3.5,
carbidopa-levodopa 25 mg-100 mg Tab [FMC],2566370,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,36.416,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.496,percent of total billed charges,40% of total billed charges,0.96,2.55,
carbidopa-levodopa 25 mg-100 mg Tab [FMC],2566370,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,63.704,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.608,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,8.272,percent of total billed charges,40% of total billed charges,0.96,2.55,
carbidopa-levodopa 25 mg-100 mg Tab [FMC],2566370,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,34.776,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.496,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.12,percent of total billed charges,40% of total billed charges,0.96,2.55,
carbidopa-levodopa 25 mg-250 mg Tab [FMC],2566388,CDM,250,RC,,,OUTPATIENT,1,EA,5.25,3.15,,4.46,85,,3.568,Percent of total billed charges,85% of total billed charges,2.63,50,,39,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.63,50,,35.104,percent of total billed charges,50% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2,38,,1.6,percent of total billed charges,38% of total billed charges,2.1,40,,0.96,percent of total billed charges,40% of total billed charges,1.68,4.46,
carbidopa-levodopa 25 mg-250 mg Tab [FMC],2566388,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,39.816,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
carbidopa-levodopa 25 mg-250 mg Tab [FMC],2566388,CDM,250,RC,,,OUTPATIENT,1,EA,3.61,2.166,,3.07,85,,2.456,Percent of total billed charges,85% of total billed charges,1.81,50,,42.072,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.81,50,,15.6,percent of total billed charges,50% of total billed charges,1.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.37,38,,1.096,percent of total billed charges,38% of total billed charges,1.44,40,,0.96,percent of total billed charges,40% of total billed charges,1.15,3.07,
carbidopa-levodopa 25 mg-250 mg Tab [FMC],2566388,CDM,250,RC,,,OUTPATIENT,1,EA,3.61,2.166,,3.07,85,,2.456,Percent of total billed charges,85% of total billed charges,1.81,50,,64.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.81,50,,6.504,percent of total billed charges,50% of total billed charges,1.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.15,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.37,38,,1.096,percent of total billed charges,38% of total billed charges,1.44,40,,0.96,percent of total billed charges,40% of total billed charges,1.15,3.07,
montelukast 10 mg Tab [FMC],2566412,CDM,250,RC,,,OUTPATIENT,1,EA,18.13,10.878,,15.41,85,,12.328,Percent of total billed charges,85% of total billed charges,9.07,50,,25.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.07,50,,23.072,percent of total billed charges,50% of total billed charges,5.79,31.95,,2.704,percent of total billed charges,31.95% of total billed charges,5.79,31.95,,2.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.89,38,,5.512,percent of total billed charges,38% of total billed charges,7.25,40,,3.384,percent of total billed charges,40% of total billed charges,5.79,15.41,
montelukast 10 mg Tab [FMC],2566412,CDM,250,RC,,,OUTPATIENT,1,EA,17.9,10.74,,15.22,85,,12.176,Percent of total billed charges,85% of total billed charges,8.95,50,,26.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.95,50,,1.2,percent of total billed charges,50% of total billed charges,5.72,31.95,,2.704,percent of total billed charges,31.95% of total billed charges,5.72,31.95,,2.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.8,38,,5.44,percent of total billed charges,38% of total billed charges,7.16,40,,3.384,percent of total billed charges,40% of total billed charges,5.72,15.22,
montelukast 10 mg Tab [FMC],2566412,CDM,250,RC,,,OUTPATIENT,1,EA,18.13,10.878,,15.41,85,,12.328,Percent of total billed charges,85% of total billed charges,9.07,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.07,50,,1.2,percent of total billed charges,50% of total billed charges,5.79,31.95,,2.776,percent of total billed charges,31.95% of total billed charges,5.79,31.95,,2.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.89,38,,5.512,percent of total billed charges,38% of total billed charges,7.25,40,,3.48,percent of total billed charges,40% of total billed charges,5.79,15.41,
montelukast 10 mg Tab [FMC],2566412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.536,percent of total billed charges,40% of total billed charges,0.96,2.55,
montelukast 10 mg Tab [FMC],2566412,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,9.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.368,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
montelukast 4 mg Che [FMC],2566420,CDM,250,RC,,,OUTPATIENT,1,EA,18.38,11.028,,15.62,85,,12.496,Percent of total billed charges,85% of total billed charges,9.19,50,,98.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.19,50,,1.2,percent of total billed charges,50% of total billed charges,5.87,31.95,,2.136,percent of total billed charges,31.95% of total billed charges,5.87,31.95,,2.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.98,38,,5.584,percent of total billed charges,38% of total billed charges,7.35,40,,2.672,percent of total billed charges,40% of total billed charges,5.87,15.62,
montelukast 4 mg Che [FMC],2566420,CDM,250,RC,,,OUTPATIENT,1,EA,11.89,7.134,,10.11,85,,8.088,Percent of total billed charges,85% of total billed charges,5.95,50,,78.888,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.95,50,,1.2,percent of total billed charges,50% of total billed charges,3.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.8,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.52,38,,3.616,percent of total billed charges,38% of total billed charges,4.76,40,,0.96,percent of total billed charges,40% of total billed charges,3.8,10.11,
montelukast 4 mg Che [FMC],2566420,CDM,250,RC,,,OUTPATIENT,1,EA,7.57,4.542,,6.43,85,,5.144,Percent of total billed charges,85% of total billed charges,3.79,50,,59.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.79,50,,2.4,percent of total billed charges,50% of total billed charges,2.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.88,38,,2.304,percent of total billed charges,38% of total billed charges,3.03,40,,0.96,percent of total billed charges,40% of total billed charges,2.42,6.43,
calcium carbonate-magnesium chloride 112 mg-64 mg EC [FMC],2566461,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,129.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium carbonate-magnesium chloride 112 mg-64 mg EC [FMC],2566461,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,50.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [FMC],2566479,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [FMC],2566479,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,130.888,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
sodium polystyrene sulfonate 15 g/60 mL Oral Susp [FMC],2566495,CDM,250,RC,,,OUTPATIENT,60,ML,36.56,21.936,,31.08,85,,24.864,Percent of total billed charges,85% of total billed charges,18.28,50,,12.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.28,50,,40.04,percent of total billed charges,50% of total billed charges,11.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.89,38,,11.112,percent of total billed charges,38% of total billed charges,14.62,40,,0.96,percent of total billed charges,40% of total billed charges,11.68,31.08,
sodium polystyrene sulfonate 15 g/60 mL Oral Susp [FMC],2566495,CDM,250,RC,,,OUTPATIENT,60,ML,81.66,48.996,,69.41,85,,55.528,Percent of total billed charges,85% of total billed charges,40.83,50,,10.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.83,50,,1.2,percent of total billed charges,50% of total billed charges,26.09,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,26.09,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.03,38,,24.824,percent of total billed charges,38% of total billed charges,32.66,40,,0.96,percent of total billed charges,40% of total billed charges,26.09,69.41,
sodium polystyrene sulfonate 15 g/60 mL Oral Susp [FMC],2566495,CDM,250,RC,,,OUTPATIENT,60,ML,100.75,60.45,,85.64,85,,68.512,Percent of total billed charges,85% of total billed charges,50.38,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.38,50,,1.2,percent of total billed charges,50% of total billed charges,32.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,32.19,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.29,38,,30.632,percent of total billed charges,38% of total billed charges,40.3,40,,0.96,percent of total billed charges,40% of total billed charges,32.19,85.64,
sodium bicarbonate 8.4% IV Sol 50 mL [FMC],2566511,CDM,250,RC,,,OUTPATIENT,50,ML,57.88,34.728,,49.2,85,,39.36,Percent of total billed charges,85% of total billed charges,28.94,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.94,50,,1.2,percent of total billed charges,50% of total billed charges,18.49,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,18.49,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.99,38,,17.592,percent of total billed charges,38% of total billed charges,23.15,40,,2.592,percent of total billed charges,40% of total billed charges,18.49,49.2,
sodium bicarbonate 8.4% IV Sol 50 mL [FMC],2566511,CDM,250,RC,,,OUTPATIENT,50,ML,585,351,,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,292.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,292.5,50,,1.2,percent of total billed charges,50% of total billed charges,186.91,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,186.91,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,222.3,38,,177.84,percent of total billed charges,38% of total billed charges,234,40,,1.28,percent of total billed charges,40% of total billed charges,186.91,497.25,
sodium bicarbonate 8.4% IV Sol 50 mL [FMC],2566511,CDM,250,RC,,,OUTPATIENT,50,ML,51.09,30.654,,43.43,85,,34.744,Percent of total billed charges,85% of total billed charges,25.55,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.55,50,,5.856,percent of total billed charges,50% of total billed charges,16.32,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,16.32,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.41,38,,15.528,percent of total billed charges,38% of total billed charges,20.44,40,,1.28,percent of total billed charges,40% of total billed charges,16.32,43.43,
sodium bicarbonate 8.4% IV Sol 50 mL [FMC],2566511,CDM,250,RC,,,OUTPATIENT,50,ML,84.98,50.988,,72.23,85,,57.784,Percent of total billed charges,85% of total billed charges,42.49,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.49,50,,5.896,percent of total billed charges,50% of total billed charges,27.15,31.95,,2.592,percent of total billed charges,31.95% of total billed charges,27.15,31.95,,2.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.29,38,,25.832,percent of total billed charges,38% of total billed charges,33.99,40,,3.248,percent of total billed charges,40% of total billed charges,27.15,72.23,
sodium bicarbonate 650mg Tab {FMC],2566529,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.152,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.44,percent of total billed charges,40% of total billed charges,0.96,2.55,
sodium bicarbonate 650mg Tab {FMC],2566529,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.016,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.48,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.856,percent of total billed charges,40% of total billed charges,0.96,2.55,
sodium bicarbonate 650mg Tab {FMC],2566529,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.04,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.776,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrocortisone sodium succinate 250mg PF Sol [FMC],2566560,CDM,250,RC,J1720,HCPCS,OUTPATIENT,1,ML,140.14,84.084,,119.12,85,,95.296,Percent of total billed charges,85% of total billed charges,26.56,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.56,136.6,,6.008,fee schedule,136.60% of BCBS custom fee schedule,49.26,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,44.77,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,53.25,38,,42.6,percent of total billed charges,38% of total billed charges,44.77,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,26.56,119.12,
methylPREDNISolone 125 mg preservative-free REC [FMC],2566586,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,ML,37.78,22.668,,32.11,85,,25.688,Percent of total billed charges,85% of total billed charges,0.41,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,6.016,fee schedule,136.60% of BCBS custom fee schedule,13.28,35.15,,2.216,percent of total billed charges,35.15% of total billed charges,575.74,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.36,38,,11.488,percent of total billed charges,38% of total billed charges,12.07,31.95,,2.776,percent of total billed charges,31.95% of total billed charges,0.41,575.74,
methylPREDNISolone  125 mg REC Injection [FMC],2566586,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,ML,24.28,14.568,,20.64,85,,16.512,Percent of total billed charges,85% of total billed charges,0.41,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,2.776,fee schedule,136.60% of BCBS custom fee schedule,8.53,35.15,,211.704,percent of total billed charges,35.15% of total billed charges,575.74,31.95,,211.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.23,38,,7.384,percent of total billed charges,38% of total billed charges,7.76,31.95,,265.048,percent of total billed charges,31.95% of total billed charges,0.41,575.74,
methylPREDNISolone 40 mg preservative-free REC [FMC],2566602,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,ML,23.46,14.076,,19.94,85,,15.952,Percent of total billed charges,85% of total billed charges,0.41,136.6,,599.152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,2.536,fee schedule,136.60% of BCBS custom fee schedule,8.25,35.15,,22.928,percent of total billed charges,35.15% of total billed charges,575.74,31.95,,22.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.91,38,,7.128,percent of total billed charges,38% of total billed charges,7.5,31.95,,28.704,percent of total billed charges,31.95% of total billed charges,0.41,575.74,
methylPREDNISolone 40 mg preservative-free REC [FMC],2566602,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,ML,25.68,15.408,,21.83,85,,17.464,Percent of total billed charges,85% of total billed charges,0.41,136.6,,28.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,2.736,fee schedule,136.60% of BCBS custom fee schedule,9.03,35.15,,1.2,percent of total billed charges,35.15% of total billed charges,575.74,31.95,,1.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.76,38,,7.808,percent of total billed charges,38% of total billed charges,8.2,31.95,,1.496,percent of total billed charges,31.95% of total billed charges,0.41,575.74,
methylprednisolone sodium succinate 2000 mg Sol [FMC],2566628,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,EA,200.28,120.168,,170.24,85,,136.192,Percent of total billed charges,85% of total billed charges,0.41,136.6,,116,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,2.776,fee schedule,136.60% of BCBS custom fee schedule,70.4,35.15,,2.072,percent of total billed charges,35.15% of total billed charges,575.74,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76.11,38,,60.888,percent of total billed charges,38% of total billed charges,63.99,31.95,,2.592,percent of total billed charges,31.95% of total billed charges,0.41,575.74,
methylprednisolone sodium succinate 2000 mg Sol [FMC],2566628,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,EA,324.12,194.472,,275.5,85,,220.4,Percent of total billed charges,85% of total billed charges,0.41,136.6,,480,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,35.16,fee schedule,136.60% of BCBS custom fee schedule,113.93,35.15,,12.648,percent of total billed charges,35.15% of total billed charges,575.74,31.95,,12.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,123.17,38,,98.536,percent of total billed charges,38% of total billed charges,103.56,31.95,,15.832,percent of total billed charges,31.95% of total billed charges,0.41,575.74,
sorbitol 70% Oral Liq 480 mL [FMC],2566669,CDM,250,RC,,,OUTPATIENT,30,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,874,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.976,percent of total billed charges,50% of total billed charges,0.96,31.95,,12.552,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,12.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,15.712,percent of total billed charges,40% of total billed charges,0.96,2.55,
sotalol 80 mg Tab [FMC],2566677,CDM,250,RC,,,OUTPATIENT,1,EA,8.33,4.998,,7.08,85,,5.664,Percent of total billed charges,85% of total billed charges,4.17,50,,1400,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.17,50,,18.192,percent of total billed charges,50% of total billed charges,2.66,31.95,,29.696,percent of total billed charges,31.95% of total billed charges,2.66,31.95,,29.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.17,38,,2.536,percent of total billed charges,38% of total billed charges,3.33,40,,37.184,percent of total billed charges,40% of total billed charges,2.66,7.08,
sotalol 80 mg Tab [FMC],2566677,CDM,250,RC,,,OUTPATIENT,1,EA,8.48,5.088,,7.21,85,,5.768,Percent of total billed charges,85% of total billed charges,4.24,50,,104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.24,50,,13.992,percent of total billed charges,50% of total billed charges,2.71,31.95,,5.192,percent of total billed charges,31.95% of total billed charges,2.71,31.95,,5.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.22,38,,2.576,percent of total billed charges,38% of total billed charges,3.39,40,,6.496,percent of total billed charges,40% of total billed charges,2.71,7.21,
sotalol 80 mg Tab [FMC],2566677,CDM,250,RC,,,OUTPATIENT,1,EA,7.54,4.524,,6.41,85,,5.128,Percent of total billed charges,85% of total billed charges,3.77,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.77,50,,19.176,percent of total billed charges,50% of total billed charges,2.41,31.95,,5.192,percent of total billed charges,31.95% of total billed charges,2.41,31.95,,5.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.87,38,,2.296,percent of total billed charges,38% of total billed charges,3.02,40,,6.496,percent of total billed charges,40% of total billed charges,2.41,6.41,
sotalol 80 mg Tab [FMC],2566677,CDM,250,RC,,,OUTPATIENT,1,EA,4.35,2.61,,3.7,85,,2.96,Percent of total billed charges,85% of total billed charges,2.18,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.18,50,,24.936,percent of total billed charges,50% of total billed charges,1.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.39,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.65,38,,1.32,percent of total billed charges,38% of total billed charges,1.74,40,,0.96,percent of total billed charges,40% of total billed charges,1.39,3.7,
spironolactone 25 mg Tab [FMC],2566693,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,140,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.184,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
spironolactone 25 mg Tab [FMC],2566693,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,159.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.184,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
spironolactone 25 mg Tab [FMC],2566693,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,318.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
spironolactone 25 mg Tab [FMC],2566693,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.784,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.84,percent of total billed charges,40% of total billed charges,0.96,2.55,
silver sulfADIAZINE Top 1% Crm 400gm [FMC],2566727,CDM,250,RC,,,OUTPATIENT,400,EA,211.09,126.654,,179.43,85,,143.544,Percent of total billed charges,85% of total billed charges,105.55,50,,128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.55,50,,2.432,percent of total billed charges,50% of total billed charges,67.44,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,67.44,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80.21,38,,64.168,percent of total billed charges,38% of total billed charges,84.44,40,,3.84,percent of total billed charges,40% of total billed charges,67.44,179.43,
silver sulfADIAZINE Top 1% Crm 400gm [FMC],2566727,CDM,250,RC,,,OUTPATIENT,400,EA,206.67,124.002,,175.67,85,,140.536,Percent of total billed charges,85% of total billed charges,103.34,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,103.34,50,,26.392,percent of total billed charges,50% of total billed charges,66.03,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,66.03,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,78.53,38,,62.824,percent of total billed charges,38% of total billed charges,82.67,40,,3.84,percent of total billed charges,40% of total billed charges,66.03,175.67,
silver sulfADIAZINE Top 1% Crm 50gm [FMC],2566735,CDM,250,RC,,,OUTPATIENT,50,EA,49.14,29.484,,41.77,85,,33.416,Percent of total billed charges,85% of total billed charges,24.57,50,,380,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.57,50,,26.392,percent of total billed charges,50% of total billed charges,15.7,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,15.7,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.67,38,,14.936,percent of total billed charges,38% of total billed charges,19.66,40,,3.84,percent of total billed charges,40% of total billed charges,15.7,41.77,
silver sulfADIAZINE Top 1% Crm 50gm [FMC],2566735,CDM,250,RC,,,OUTPATIENT,50,EA,50.38,30.228,,42.82,85,,34.256,Percent of total billed charges,85% of total billed charges,25.19,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.19,50,,26.392,percent of total billed charges,50% of total billed charges,16.1,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,16.1,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.14,38,,15.312,percent of total billed charges,38% of total billed charges,20.15,40,,3.84,percent of total billed charges,40% of total billed charges,16.1,42.82,
silver sulfADIAZINE Top 1% Crm 50gm [FMC],2566735,CDM,250,RC,,,OUTPATIENT,50,EA,52.27,31.362,,44.43,85,,35.544,Percent of total billed charges,85% of total billed charges,26.14,50,,136,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.14,50,,26.392,percent of total billed charges,50% of total billed charges,16.7,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,16.7,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.86,38,,15.888,percent of total billed charges,38% of total billed charges,20.91,40,,0.96,percent of total billed charges,40% of total billed charges,16.7,44.43,
nateglinide 60 mg Tab [FMC],2566750,CDM,250,RC,,,OUTPATIENT,1,EA,5.4,3.24,,4.59,85,,3.672,Percent of total billed charges,85% of total billed charges,2.7,50,,280,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.7,50,,26.392,percent of total billed charges,50% of total billed charges,1.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.05,38,,1.64,percent of total billed charges,38% of total billed charges,2.16,40,,0.96,percent of total billed charges,40% of total billed charges,1.73,4.59,
nateglinide 60 mg Tab [FMC],2566750,CDM,250,RC,,,OUTPATIENT,1,EA,6.7,4.02,,5.7,85,,4.56,Percent of total billed charges,85% of total billed charges,3.35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.35,50,,26.392,percent of total billed charges,50% of total billed charges,2.14,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.14,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.55,38,,2.04,percent of total billed charges,38% of total billed charges,2.68,40,,0.96,percent of total billed charges,40% of total billed charges,2.14,5.7,
nateglinide 60 mg Tab [FMC],2566750,CDM,250,RC,,,OUTPATIENT,1,EA,5.4,3.24,,4.59,85,,3.672,Percent of total billed charges,85% of total billed charges,2.7,50,,38,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.7,50,,1.2,percent of total billed charges,50% of total billed charges,1.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.05,38,,1.64,percent of total billed charges,38% of total billed charges,2.16,40,,0.96,percent of total billed charges,40% of total billed charges,1.73,4.59,
sucralfate 1 g Tab UD [FMC],2566784,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,920,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.784,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
sucralfate 1 g Tab UD [FMC],2566784,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,468,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.472,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
sucralfate 1 g Tab UD [FMC],2566784,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.464,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.336,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
sucralfate 1 g Tab UD [FMC] -  - Inpatient - FMC HOSP - Active - 00093-2210-05,2566784,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,21.872,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.896,percent of total billed charges,40% of total billed charges,0.96,2.55,
sucralfate 1 g Tab,2566784,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,24.576,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.152,percent of total billed charges,40% of total billed charges,0.96,2.55,
sulfamethoxazole-trimethoprim 800 mg-160 mg 10 mL IV Sol [FMC],2566826,CDM,250,RC,,,OUTPATIENT,10,ML,48.91,29.346,,41.57,85,,33.256,Percent of total billed charges,85% of total billed charges,24.46,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.46,50,,4.872,percent of total billed charges,50% of total billed charges,15.63,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,15.63,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.59,38,,14.872,percent of total billed charges,38% of total billed charges,19.56,40,,1.76,percent of total billed charges,40% of total billed charges,15.63,41.57,
sodium sulfacetamide Ophth 10% Sol [FMC],2566834,CDM,250,RC,,,OUTPATIENT,15,EA,180.86,108.516,,153.73,85,,122.984,Percent of total billed charges,85% of total billed charges,90.43,50,,240,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90.43,50,,4.88,percent of total billed charges,50% of total billed charges,57.78,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,57.78,31.95,,1.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.73,38,,54.984,percent of total billed charges,38% of total billed charges,72.34,40,,1.728,percent of total billed charges,40% of total billed charges,57.78,153.73,
sodium sulfacetamide Ophth 10% Sol [FMC],2566834,CDM,250,RC,,,OUTPATIENT,15,EA,187.69,112.614,,159.54,85,,127.632,Percent of total billed charges,85% of total billed charges,93.85,50,,240,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,93.85,50,,4.88,percent of total billed charges,50% of total billed charges,59.97,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,59.97,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.32,38,,57.056,percent of total billed charges,38% of total billed charges,75.08,40,,1.76,percent of total billed charges,40% of total billed charges,59.97,159.54,
sodium sulfacetamide Ophth 10% Sol [FMC],2566834,CDM,250,RC,,,OUTPATIENT,15,EA,198.25,118.95,,168.51,85,,134.808,Percent of total billed charges,85% of total billed charges,99.13,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,99.13,50,,13.944,percent of total billed charges,50% of total billed charges,63.34,31.95,,78.92,percent of total billed charges,31.95% of total billed charges,63.34,31.95,,78.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,75.34,38,,60.272,percent of total billed charges,38% of total billed charges,79.3,40,,98.8,percent of total billed charges,40% of total billed charges,63.34,168.51,
sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [FMC],2566842,CDM,250,RC,,,OUTPATIENT,5,ML,7.4,4.44,,6.29,85,,5.032,Percent of total billed charges,85% of total billed charges,3.7,50,,140.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.7,50,,13.944,percent of total billed charges,50% of total billed charges,2.36,31.95,,20.256,percent of total billed charges,31.95% of total billed charges,2.36,31.95,,20.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.81,38,,2.248,percent of total billed charges,38% of total billed charges,2.96,40,,25.36,percent of total billed charges,40% of total billed charges,2.36,6.29,
sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [FMC],2566842,CDM,250,RC,,,OUTPATIENT,5,ML,3.88,2.328,,3.3,85,,2.64,Percent of total billed charges,85% of total billed charges,1.94,50,,140.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.94,50,,17.536,percent of total billed charges,50% of total billed charges,1.24,31.95,,39.872,percent of total billed charges,31.95% of total billed charges,1.24,31.95,,39.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.47,38,,1.176,percent of total billed charges,38% of total billed charges,1.55,40,,49.92,percent of total billed charges,40% of total billed charges,1.24,3.3,
sulfaSALAzine 500 mg Tab [FMC],2566859,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,221.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,9.648,percent of total billed charges,50% of total billed charges,0.96,31.95,,13.088,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,13.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,16.384,percent of total billed charges,40% of total billed charges,0.96,2.55,
sulfaSALAzine 500 mg Tab [FMC],2566859,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,221.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.688,percent of total billed charges,50% of total billed charges,0.96,31.95,,53.696,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,53.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,67.224,percent of total billed charges,40% of total billed charges,0.96,2.55,
sulfaSALAzine 500 mg Tab [FMC],2566859,CDM,250,RC,,,OUTPATIENT,1,EA,3.9,2.34,,3.32,85,,2.656,Percent of total billed charges,85% of total billed charges,1.95,50,,160.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.95,50,,6.4,percent of total billed charges,50% of total billed charges,1.25,31.95,,2.12,percent of total billed charges,31.95% of total billed charges,1.25,31.95,,2.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.48,38,,1.184,percent of total billed charges,38% of total billed charges,1.56,40,,2.648,percent of total billed charges,40% of total billed charges,1.25,3.32,
levothyroxine 112 mcg (0.112 mg) Tab [FMC],2566941,CDM,250,RC,,,OUTPATIENT,1,EA,3.26,1.956,,2.77,85,,2.216,Percent of total billed charges,85% of total billed charges,1.63,50,,210,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.63,50,,5.728,percent of total billed charges,50% of total billed charges,1.04,31.95,,1.464,percent of total billed charges,31.95% of total billed charges,1.04,31.95,,1.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.24,38,,0.992,percent of total billed charges,38% of total billed charges,1.3,40,,1.832,percent of total billed charges,40% of total billed charges,1.04,2.77,
levothyroxine 112 mcg (0.112 mg) Tab [FMC],2566941,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,210,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.256,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 112 mcg (0.112 mg) Tab [FMC],2566941,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,210,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.704,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.64,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 100 mcg (0.1 mg) Tab [FMC],2566974,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,69.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.224,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.736,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.68,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 100 mcg (0.1 mg) Tab [FMC],2566974,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,69.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.184,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.848,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 100 mcg (0.1 mg) Tab [FMC],2566974,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,69.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.192,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.928,percent of total billed charges,40% of total billed charges,0.96,2.55,
levothyroxine 100 mcg (0.1 mg) Tab [FMC],2566974,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,236,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.32,percent of total billed charges,50% of total billed charges,0.96,31.95,,8.344,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,8.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,10.448,percent of total billed charges,40% of total billed charges,0.96,2.55,
flecainide 50 mg Tab [FMC],2567048,CDM,250,RC,,,OUTPATIENT,1,EA,5.66,3.396,,4.81,85,,3.848,Percent of total billed charges,85% of total billed charges,2.83,50,,42.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.83,50,,1.2,percent of total billed charges,50% of total billed charges,1.81,31.95,,5.032,percent of total billed charges,31.95% of total billed charges,1.81,31.95,,5.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.15,38,,1.72,percent of total billed charges,38% of total billed charges,2.26,40,,6.304,percent of total billed charges,40% of total billed charges,1.81,4.81,
flecainide 50 mg Tab [FMC],2567048,CDM,250,RC,,,OUTPATIENT,1,EA,6.56,3.936,,5.58,85,,4.464,Percent of total billed charges,85% of total billed charges,3.28,50,,90,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.28,50,,4.536,percent of total billed charges,50% of total billed charges,2.1,31.95,,8.72,percent of total billed charges,31.95% of total billed charges,2.1,31.95,,8.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.49,38,,1.992,percent of total billed charges,38% of total billed charges,2.62,40,,10.92,percent of total billed charges,40% of total billed charges,2.1,5.58,
flecainide 50 mg Tab [FMC],2567048,CDM,250,RC,,,OUTPATIENT,1,EA,6.56,3.936,,5.58,85,,4.464,Percent of total billed charges,85% of total billed charges,3.28,50,,230,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.28,50,,1.2,percent of total billed charges,50% of total billed charges,2.1,31.95,,6.752,percent of total billed charges,31.95% of total billed charges,2.1,31.95,,6.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.49,38,,1.992,percent of total billed charges,38% of total billed charges,2.62,40,,8.456,percent of total billed charges,40% of total billed charges,2.1,5.58,
flecainide 50 mg Tab [FMC],2567048,CDM,250,RC,,,OUTPATIENT,1,EA,8.32,4.992,,7.07,85,,5.656,Percent of total billed charges,85% of total billed charges,4.16,50,,230,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.16,50,,5.928,percent of total billed charges,50% of total billed charges,2.66,31.95,,5.984,percent of total billed charges,31.95% of total billed charges,2.66,31.95,,5.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.16,38,,2.528,percent of total billed charges,38% of total billed charges,3.33,40,,7.488,percent of total billed charges,40% of total billed charges,2.66,7.07,
oseltamivir 75 mg Cap [FMC],2567055,CDM,250,RC,,,OUTPATIENT,1,EA,59.23,35.538,,50.35,85,,40.28,Percent of total billed charges,85% of total billed charges,29.62,50,,318.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.62,50,,4.8,percent of total billed charges,50% of total billed charges,18.92,31.95,,5.856,percent of total billed charges,31.95% of total billed charges,18.92,31.95,,5.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.51,38,,18.008,percent of total billed charges,38% of total billed charges,23.69,40,,7.328,percent of total billed charges,40% of total billed charges,18.92,50.35,
oseltamivir 75 mg Cap [FMC],2567055,CDM,250,RC,,,OUTPATIENT,1,EA,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,318.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,1.2,percent of total billed charges,50% of total billed charges,15.02,31.95,,11.464,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,11.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,14.288,percent of total billed charges,38% of total billed charges,18.8,40,,14.352,percent of total billed charges,40% of total billed charges,15.02,39.95,
oseltamivir 75 mg Cap [FMC],2567055,CDM,250,RC,,,OUTPATIENT,1,EA,50.24,30.144,,42.7,85,,34.16,Percent of total billed charges,85% of total billed charges,25.12,50,,318.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.12,50,,9.36,percent of total billed charges,50% of total billed charges,16.05,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,16.05,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.09,38,,15.272,percent of total billed charges,38% of total billed charges,20.1,40,,7.688,percent of total billed charges,40% of total billed charges,16.05,42.7,
temazepam 15 mg Cap [FMC],2567261,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,318.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,10.688,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.296,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,10.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,12.896,percent of total billed charges,40% of total billed charges,1.28,3.4,
temazepam 15 mg Cap [FMC],2567261,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,318.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,6.384,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.976,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,10.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,13.736,percent of total billed charges,40% of total billed charges,1.28,3.4,
temazepam 15 mg Cap [FMC],2567261,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,318.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,9.248,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.976,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,10.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,13.736,percent of total billed charges,40% of total billed charges,1.28,3.4,
temazepam 15 mg Cap,2567261,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,318.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,2.184,percent of total billed charges,50% of total billed charges,1.28,31.95,,9.384,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,9.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,11.744,percent of total billed charges,40% of total billed charges,1.28,3.4,
terazosin 1 mg Cap [FMC],2567352,CDM,250,RC,,,OUTPATIENT,1,EA,5.22,3.132,,4.44,85,,3.552,Percent of total billed charges,85% of total billed charges,2.61,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.61,50,,1.2,percent of total billed charges,50% of total billed charges,1.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.09,40,,0.96,percent of total billed charges,40% of total billed charges,1.67,4.44,
terazosin 1 mg Cap [FMC],2567352,CDM,250,RC,,,OUTPATIENT,1,EA,4.7,2.82,,4,85,,3.2,Percent of total billed charges,85% of total billed charges,2.35,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.35,50,,1.2,percent of total billed charges,50% of total billed charges,1.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.5,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.79,38,,1.432,percent of total billed charges,38% of total billed charges,1.88,40,,0.96,percent of total billed charges,40% of total billed charges,1.5,4,
terazosin 1 mg Cap [FMC],2567352,CDM,250,RC,,,OUTPATIENT,1,EA,5.21,3.126,,4.43,85,,3.544,Percent of total billed charges,85% of total billed charges,2.61,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.61,50,,1.2,percent of total billed charges,50% of total billed charges,1.66,31.95,,4.2,percent of total billed charges,31.95% of total billed charges,1.66,31.95,,4.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.08,40,,5.264,percent of total billed charges,40% of total billed charges,1.66,4.43,
terazosin 1 mg Cap [FMC],2567352,CDM,250,RC,,,OUTPATIENT,1,EA,5.22,3.132,,4.44,85,,3.552,Percent of total billed charges,85% of total billed charges,2.61,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.61,50,,1.696,percent of total billed charges,50% of total billed charges,1.67,31.95,,4.104,percent of total billed charges,31.95% of total billed charges,1.67,31.95,,4.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.09,40,,5.136,percent of total billed charges,40% of total billed charges,1.67,4.44,
terazosin 1 mg Cap [FMC],2567352,CDM,250,RC,,,OUTPATIENT,1,EA,5.22,3.132,,4.44,85,,3.552,Percent of total billed charges,85% of total billed charges,2.61,50,,255.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.61,50,,1.2,percent of total billed charges,50% of total billed charges,1.67,31.95,,4.104,percent of total billed charges,31.95% of total billed charges,1.67,31.95,,4.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.09,40,,5.136,percent of total billed charges,40% of total billed charges,1.67,4.44,
terazosin 5 mg Cap [FMC],2567386,CDM,250,RC,,,OUTPATIENT,1,EA,5.22,3.132,,4.44,85,,3.552,Percent of total billed charges,85% of total billed charges,2.61,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.61,50,,9.528,percent of total billed charges,50% of total billed charges,1.67,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,1.67,31.95,,26.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.09,40,,28.976,percent of total billed charges,40% of total billed charges,1.67,4.44,
terazosin 5 mg Cap [FMC],2567386,CDM,250,RC,,,OUTPATIENT,1,EA,4.7,2.82,,4,85,,3.2,Percent of total billed charges,85% of total billed charges,2.35,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.35,50,,9.568,percent of total billed charges,50% of total billed charges,1.5,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,1.5,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.79,38,,1.432,percent of total billed charges,38% of total billed charges,1.88,40,,28.976,percent of total billed charges,40% of total billed charges,1.5,4,
terazosin 5 mg Cap [FMC],2567386,CDM,250,RC,,,OUTPATIENT,1,EA,5.22,3.132,,4.44,85,,3.552,Percent of total billed charges,85% of total billed charges,2.61,50,,223.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.61,50,,6.888,percent of total billed charges,50% of total billed charges,1.67,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,1.67,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.98,38,,1.584,percent of total billed charges,38% of total billed charges,2.09,40,,28.976,percent of total billed charges,40% of total billed charges,1.67,4.44,
terahydolozine 0.05 % Sol [FMC],2567428,CDM,250,RC,,,OUTPATIENT,15,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,261.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,84.568,percent of total billed charges,50% of total billed charges,1.92,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,29.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,28.976,percent of total billed charges,40% of total billed charges,1.92,5.1,
terahydolozine 0.05 % Sol [FMC],2567428,CDM,250,RC,,,OUTPATIENT,15,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,318.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,4.528,percent of total billed charges,50% of total billed charges,1.92,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,28.976,percent of total billed charges,40% of total billed charges,1.92,5.1,
terahydolozine 0.05 % Sol [FMC],2567428,CDM,250,RC,,,OUTPATIENT,15,EA,6.18,3.708,,5.25,85,,4.2,Percent of total billed charges,85% of total billed charges,3.09,50,,135.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.09,50,,8.624,percent of total billed charges,50% of total billed charges,1.97,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,1.97,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.35,38,,1.88,percent of total billed charges,38% of total billed charges,2.47,40,,28.976,percent of total billed charges,40% of total billed charges,1.97,5.25,
tetracaine Opth 0.5% Sol [FMC],2567436,CDM,250,RC,,,OUTPATIENT,4,EA,45.44,27.264,,38.62,85,,30.896,Percent of total billed charges,85% of total billed charges,22.72,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.72,50,,4.368,percent of total billed charges,50% of total billed charges,14.52,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,14.52,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.27,38,,13.816,percent of total billed charges,38% of total billed charges,18.18,40,,28.976,percent of total billed charges,40% of total billed charges,14.52,38.62,
elixophyllin Elixir theophylline anhydrous 80mg/15ml [FMC],2567485,CDM,250,RC,,,OUTPATIENT,15,ML,10.82,6.492,,9.2,85,,7.36,Percent of total billed charges,85% of total billed charges,5.41,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.41,50,,6.16,percent of total billed charges,50% of total billed charges,3.46,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,3.46,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.11,38,,3.288,percent of total billed charges,38% of total billed charges,4.33,40,,28.976,percent of total billed charges,40% of total billed charges,3.46,9.2,
elixophyllin Elixir theophylline anhydrous 80mg/15ml [FMC],2567485,CDM,250,RC,,,OUTPATIENT,15,ML,11.52,6.912,,9.79,85,,7.832,Percent of total billed charges,85% of total billed charges,5.76,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.76,50,,21.832,percent of total billed charges,50% of total billed charges,3.68,31.95,,31.88,percent of total billed charges,31.95% of total billed charges,3.68,31.95,,29.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.38,38,,3.504,percent of total billed charges,38% of total billed charges,4.61,40,,28.976,percent of total billed charges,40% of total billed charges,3.68,9.79,
Multiple Vitamins Tab [FMC],2567527,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,120,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.776,percent of total billed charges,40% of total billed charges,0.96,2.55,
thiamine 100 mg/mL Inj Sol 2mL [FMC],2567543,CDM,250,RC,J3411,HCPCS,OUTPATIENT,2,ML,34.67,20.802,,29.47,85,,23.576,Percent of total billed charges,85% of total billed charges,3.89,136.6,,62,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.89,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,12.19,35.15,,3.496,percent of total billed charges,35.15% of total billed charges,608.97,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.17,38,,10.536,percent of total billed charges,38% of total billed charges,11.08,31.95,,4.376,percent of total billed charges,31.95% of total billed charges,3.89,608.97,
thiamine 100 mg/mL Inj Sol 2mL [FMC],2567543,CDM,250,RC,J3411,HCPCS,OUTPATIENT,2,ML,38.81,23.286,,32.99,85,,26.392,Percent of total billed charges,85% of total billed charges,3.89,136.6,,140,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.89,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,13.64,35.15,,3.504,percent of total billed charges,35.15% of total billed charges,619.83,31.95,,3.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.75,38,,11.8,percent of total billed charges,38% of total billed charges,12.4,31.95,,4.384,percent of total billed charges,31.95% of total billed charges,3.89,619.83,
thiamine 100 mg/mL Inj Sol 2mL [FMC],2567543,CDM,250,RC,J3411,HCPCS,OUTPATIENT,2,ML,40.42,24.252,,34.36,85,,27.488,Percent of total billed charges,85% of total billed charges,3.89,136.6,,256.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.89,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,14.21,35.15,,1.232,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,1.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.36,38,,12.288,percent of total billed charges,38% of total billed charges,12.91,31.95,,1.544,percent of total billed charges,31.95% of total billed charges,3.89,623.03,
thiamine 100 mg/mL Inj Sol 2mL [FMC],2567543,CDM,250,RC,J3411,HCPCS,OUTPATIENT,2,ML,38.81,23.286,,32.99,85,,26.392,Percent of total billed charges,85% of total billed charges,3.89,136.6,,256.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.89,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,13.64,35.15,,2.088,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,2.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.75,38,,11.8,percent of total billed charges,38% of total billed charges,12.4,31.95,,2.616,percent of total billed charges,31.95% of total billed charges,3.89,623.03,
thiamine 100 mg/mL Inj Sol 2mL [FMC],2567543,CDM,250,RC,J3411,HCPCS,OUTPATIENT,2,ML,38.81,23.286,,32.99,85,,26.392,Percent of total billed charges,85% of total billed charges,3.89,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.89,136.6,,161.2,fee schedule,136.60% of BCBS custom fee schedule,13.64,35.15,,6.464,percent of total billed charges,35.15% of total billed charges,31.95,31.95,,6.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.75,38,,11.8,percent of total billed charges,38% of total billed charges,12.4,31.95,,8.096,percent of total billed charges,31.95% of total billed charges,3.89,32.99,
thioridazine 10 mg Tab [FMC],2567550,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,170,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.504,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.232,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.544,percent of total billed charges,40% of total billed charges,0.96,2.55,
thioridazine 10 mg Tab [FMC],2567550,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,22.088,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.232,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.544,percent of total billed charges,40% of total billed charges,0.96,2.55,
thioridazine 25 mg Tab UD [FMC],2567584,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,8.152,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,29.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.408,percent of total billed charges,40% of total billed charges,0.96,2.55,
thioridazine 25 mg Tab UD [FMC],2567584,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.152,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.584,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,29.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.984,percent of total billed charges,40% of total billed charges,0.96,2.55,
timolol ophthalmic maleate 0.25% Sol [FMC],2567691,CDM,250,RC,,,OUTPATIENT,5,EA,538.94,323.364,,458.1,85,,366.48,Percent of total billed charges,85% of total billed charges,269.47,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,269.47,50,,14.4,percent of total billed charges,50% of total billed charges,172.19,31.95,,5.48,percent of total billed charges,31.95% of total billed charges,172.19,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,204.8,38,,163.84,percent of total billed charges,38% of total billed charges,215.58,40,,4.984,percent of total billed charges,40% of total billed charges,172.19,458.1,
timolol ophthalmic maleate 0.25% Sol [FMC],2567691,CDM,250,RC,,,OUTPATIENT,5,EA,48.75,29.25,,41.44,85,,33.152,Percent of total billed charges,85% of total billed charges,24.38,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.38,50,,14.4,percent of total billed charges,50% of total billed charges,15.58,31.95,,8.152,percent of total billed charges,31.95% of total billed charges,15.58,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.53,38,,14.824,percent of total billed charges,38% of total billed charges,19.5,40,,7.408,percent of total billed charges,40% of total billed charges,15.58,41.44,
timolol ophthalmic maleate 0.25% Sol [FMC],2567691,CDM,250,RC,,,OUTPATIENT,5,EA,11.64,6.984,,9.89,85,,7.912,Percent of total billed charges,85% of total billed charges,5.82,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.82,50,,7.104,percent of total billed charges,50% of total billed charges,3.72,31.95,,15.808,percent of total billed charges,31.95% of total billed charges,3.72,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.42,38,,3.536,percent of total billed charges,38% of total billed charges,4.66,40,,14.376,percent of total billed charges,40% of total billed charges,3.72,9.89,
timolol Ophth 0.5% Sol [FMC],2567725,CDM,250,RC,,,OUTPATIENT,15,EA,158.44,95.064,,134.67,85,,107.736,Percent of total billed charges,85% of total billed charges,79.22,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79.22,50,,9.36,percent of total billed charges,50% of total billed charges,50.62,31.95,,10.976,percent of total billed charges,31.95% of total billed charges,50.62,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.21,38,,48.168,percent of total billed charges,38% of total billed charges,63.38,40,,9.976,percent of total billed charges,40% of total billed charges,50.62,134.67,
timolol ophthalmic maleate 0.5% Sol [FMC],2567725,CDM,250,RC,,,OUTPATIENT,15,EA,165.75,99.45,,140.89,85,,112.712,Percent of total billed charges,85% of total billed charges,82.88,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,82.88,50,,9.728,percent of total billed charges,50% of total billed charges,52.96,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,52.96,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,62.99,38,,50.392,percent of total billed charges,38% of total billed charges,66.3,40,,5.12,percent of total billed charges,40% of total billed charges,52.96,140.89,
timolol ophthalmic maleate 0.5% Sol [FMC],2567725,CDM,250,RC,,,OUTPATIENT,15,EA,165.75,99.45,,140.89,85,,112.712,Percent of total billed charges,85% of total billed charges,82.88,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,82.88,50,,10.16,percent of total billed charges,50% of total billed charges,52.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,52.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,62.99,38,,50.392,percent of total billed charges,38% of total billed charges,66.3,40,,0.96,percent of total billed charges,40% of total billed charges,52.96,140.89,
timolol ophthalmic maleate 0.5% Sol [FMC],2567725,CDM,250,RC,,,OUTPATIENT,15,EA,42.9,25.74,,36.47,85,,29.176,Percent of total billed charges,85% of total billed charges,21.45,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.45,50,,268.16,percent of total billed charges,50% of total billed charges,13.71,31.95,,3.656,percent of total billed charges,31.95% of total billed charges,13.71,31.95,,3.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.3,38,,13.04,percent of total billed charges,38% of total billed charges,17.16,40,,4.576,percent of total billed charges,40% of total billed charges,13.71,36.47,
timolol ophthalmic maleate 0.5% Sol [FMC],2567725,CDM,250,RC,,,OUTPATIENT,15,EA,36.08,21.648,,30.67,85,,24.536,Percent of total billed charges,85% of total billed charges,18.04,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.04,50,,327.6,percent of total billed charges,50% of total billed charges,11.53,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,11.53,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.71,38,,10.968,percent of total billed charges,38% of total billed charges,14.43,40,,5.12,percent of total billed charges,40% of total billed charges,11.53,30.67,
timolol ophthalmic maleate 0.5% Sol [FMC],2567725,CDM,250,RC,,,OUTPATIENT,15,EA,63.96,38.376,,54.37,85,,43.496,Percent of total billed charges,85% of total billed charges,31.98,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.98,50,,8.816,percent of total billed charges,50% of total billed charges,20.44,31.95,,5.504,percent of total billed charges,31.95% of total billed charges,20.44,31.95,,5.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.3,38,,19.44,percent of total billed charges,38% of total billed charges,25.58,40,,6.896,percent of total billed charges,40% of total billed charges,20.44,54.37,
tenecteplase 50 mg IV Inj [FMC],2567758,CDM,250,RC,J3101,HCPCS,OUTPATIENT,1,EA,13631.46,8178.876,,11586.74,85,,9269.392,Percent of total billed charges,85% of total billed charges,230.05,136.6,,92.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,230.05,136.6,,1.24,fee schedule,136.60% of BCBS custom fee schedule,4791.46,35.15,,2.248,percent of total billed charges,35.15% of total billed charges,31.95,31.95,,2.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5179.95,38,,4143.96,percent of total billed charges,38% of total billed charges,4355.25,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,31.95,11586.74,
tobramycin Opth 0.3% Sol [FMC],2567766,CDM,250,RC,,,OUTPATIENT,5,EA,47.32,28.392,,40.22,85,,32.176,Percent of total billed charges,85% of total billed charges,23.66,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.66,50,,7.936,percent of total billed charges,50% of total billed charges,15.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,15.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.98,38,,14.384,percent of total billed charges,38% of total billed charges,18.93,40,,0.96,percent of total billed charges,40% of total billed charges,15.12,40.22,
tobramycin Opth 0.3% Sol [FMC],2567766,CDM,250,RC,,,OUTPATIENT,5,EA,110.44,66.264,,93.87,85,,75.096,Percent of total billed charges,85% of total billed charges,55.22,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,55.22,50,,35.672,percent of total billed charges,50% of total billed charges,35.29,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,35.29,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.97,38,,33.576,percent of total billed charges,38% of total billed charges,44.18,40,,0.96,percent of total billed charges,40% of total billed charges,35.29,93.87,
tobramycin Opth 0.3% Sol [FMC],2567766,CDM,250,RC,,,OUTPATIENT,5,EA,20.31,12.186,,17.26,85,,13.808,Percent of total billed charges,85% of total billed charges,10.16,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.16,50,,20.28,percent of total billed charges,50% of total billed charges,6.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.72,38,,6.176,percent of total billed charges,38% of total billed charges,8.12,40,,0.96,percent of total billed charges,40% of total billed charges,6.49,17.26,
tobramycin 40mg/ml Sol [FMC],2567782,CDM,250,RC,J3260,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,3.29,136.6,,294,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.29,136.6,,21.064,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.64,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,2.056,Fee Schedule,31.95% of LA custom fee schedule,3.29,10.2,
tobramycin 40mg/ml Sol [FMC],2567782,CDM,250,RC,J3260,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,3.29,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.29,136.6,,21.968,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.432,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.792,Fee Schedule,31.95% of LA custom fee schedule,3.29,10.2,
tobramycin 40mg/ml Sol [FMC],2567782,CDM,250,RC,J3260,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,3.29,136.6,,160,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.29,136.6,,5.512,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.824,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.824,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,2.28,Fee Schedule,31.95% of LA custom fee schedule,3.29,10.2,
dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [FMC],2567808,CDM,250,RC,,,OUTPATIENT,3.5,EA,672.36,403.416,,571.51,85,,457.208,Percent of total billed charges,85% of total billed charges,336.18,50,,120,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,336.18,50,,7.456,percent of total billed charges,50% of total billed charges,214.82,31.95,,19.88,percent of total billed charges,31.95% of total billed charges,214.82,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,255.5,38,,204.4,percent of total billed charges,38% of total billed charges,268.94,40,,18.072,percent of total billed charges,40% of total billed charges,214.82,571.51,
dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [FMC],2567808,CDM,250,RC,,,OUTPATIENT,3.5,EA,890.01,534.006,,756.51,85,,605.208,Percent of total billed charges,85% of total billed charges,445.01,50,,1184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,445.01,50,,5.512,percent of total billed charges,50% of total billed charges,284.36,31.95,,15.208,percent of total billed charges,31.95% of total billed charges,284.36,31.95,,30.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,338.2,38,,270.56,percent of total billed charges,38% of total billed charges,356,40,,13.824,percent of total billed charges,40% of total billed charges,284.36,756.51,
topiramate 100 mg Tab [FMC],2567840,CDM,250,RC,,,OUTPATIENT,1,EA,22.63,13.578,,19.24,85,,15.392,Percent of total billed charges,85% of total billed charges,11.32,50,,1709.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.32,50,,1.2,percent of total billed charges,50% of total billed charges,7.23,31.95,,21.792,percent of total billed charges,31.95% of total billed charges,7.23,31.95,,31.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.6,38,,6.88,percent of total billed charges,38% of total billed charges,9.05,40,,19.808,percent of total billed charges,40% of total billed charges,7.23,19.24,
topiramate 100 mg Tab [FMC],2567840,CDM,250,RC,,,OUTPATIENT,1,EA,20.15,12.09,,17.13,85,,13.704,Percent of total billed charges,85% of total billed charges,10.08,50,,104.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.08,50,,1.72,percent of total billed charges,50% of total billed charges,6.44,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,6.44,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.66,38,,6.128,percent of total billed charges,38% of total billed charges,8.06,40,,12.08,percent of total billed charges,40% of total billed charges,6.44,17.13,
topiramate 25 mg Tab [FMC],2567857,CDM,250,RC,,,OUTPATIENT,1,EA,8.21,4.926,,6.98,85,,5.584,Percent of total billed charges,85% of total billed charges,4.11,50,,104.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.11,50,,1.2,percent of total billed charges,50% of total billed charges,2.62,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,2.62,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.12,38,,2.496,percent of total billed charges,38% of total billed charges,3.28,40,,15.336,percent of total billed charges,40% of total billed charges,2.62,6.98,
Topiramate 25mg Tab [FMC],2567857,CDM,250,RC,,,OUTPATIENT,1,EA,6.83,4.098,,5.81,85,,4.648,Percent of total billed charges,85% of total billed charges,3.42,50,,104.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.42,50,,1.384,percent of total billed charges,50% of total billed charges,2.18,31.95,,19.88,percent of total billed charges,31.95% of total billed charges,2.18,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.6,38,,2.08,percent of total billed charges,38% of total billed charges,2.73,40,,18.072,percent of total billed charges,40% of total billed charges,2.18,5.81,
metoprolol succ 25 mg ER Tab [FMC],2567881,CDM,250,RC,,,OUTPATIENT,1,EA,3.8,2.28,,3.23,85,,2.584,Percent of total billed charges,85% of total billed charges,1.9,50,,104.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.9,50,,1.6,percent of total billed charges,50% of total billed charges,1.21,31.95,,12.064,percent of total billed charges,31.95% of total billed charges,1.21,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.44,38,,1.152,percent of total billed charges,38% of total billed charges,1.52,40,,10.968,percent of total billed charges,40% of total billed charges,1.21,3.23,
metoprolol succ 25 mg ER Tab [FMC],2567881,CDM,250,RC,,,OUTPATIENT,1,EA,3.62,2.172,,3.08,85,,2.464,Percent of total billed charges,85% of total billed charges,1.81,50,,104.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.81,50,,1.6,percent of total billed charges,50% of total billed charges,1.16,31.95,,10.368,percent of total billed charges,31.95% of total billed charges,1.16,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.38,38,,1.104,percent of total billed charges,38% of total billed charges,1.45,40,,9.424,percent of total billed charges,40% of total billed charges,1.16,3.08,
metoprolol succ 25 mg ER Tab [FMC],2567881,CDM,250,RC,,,OUTPATIENT,1,EA,4.03,2.418,,3.43,85,,2.744,Percent of total billed charges,85% of total billed charges,2.02,50,,154,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.02,50,,1.2,percent of total billed charges,50% of total billed charges,1.29,31.95,,15.208,percent of total billed charges,31.95% of total billed charges,1.29,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.53,38,,1.224,percent of total billed charges,38% of total billed charges,1.61,40,,13.824,percent of total billed charges,40% of total billed charges,1.29,3.43,
metoprolol succ 25 mg ER Tab [FMC],2567881,CDM,250,RC,,,OUTPATIENT,1,EA,3.62,2.172,,3.08,85,,2.464,Percent of total billed charges,85% of total billed charges,1.81,50,,154,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.81,50,,1.2,percent of total billed charges,50% of total billed charges,1.16,31.95,,15.208,percent of total billed charges,31.95% of total billed charges,1.16,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.38,38,,1.104,percent of total billed charges,38% of total billed charges,1.45,40,,13.824,percent of total billed charges,40% of total billed charges,1.16,3.08,
metoprolol succ 25 mg ER Tab [FMC],2567881,CDM,250,RC,,,OUTPATIENT,1,EA,3.58,2.148,,3.04,85,,2.432,Percent of total billed charges,85% of total billed charges,1.79,50,,154,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.79,50,,5.944,percent of total billed charges,50% of total billed charges,1.14,31.95,,6.248,percent of total billed charges,31.95% of total billed charges,1.14,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.36,38,,1.088,percent of total billed charges,38% of total billed charges,1.43,40,,5.68,percent of total billed charges,40% of total billed charges,1.14,3.04,
metoprolol Succinate 50 mg ER Tab [FMC],2567899,CDM,250,RC,,,OUTPATIENT,1,EA,3.62,2.172,,3.08,85,,2.464,Percent of total billed charges,85% of total billed charges,1.81,50,,154,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.81,50,,5.744,percent of total billed charges,50% of total billed charges,1.16,31.95,,5.648,percent of total billed charges,31.95% of total billed charges,1.16,31.95,,34.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.38,38,,1.104,percent of total billed charges,38% of total billed charges,1.45,40,,5.136,percent of total billed charges,40% of total billed charges,1.16,3.08,
metoprolol Succinate 50 mg ER Tab [FMC],2567899,CDM,250,RC,,,OUTPATIENT,1,EA,4.03,2.418,,3.43,85,,2.744,Percent of total billed charges,85% of total billed charges,2.02,50,,154,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.02,50,,1.4,percent of total billed charges,50% of total billed charges,1.29,31.95,,15.696,percent of total billed charges,31.95% of total billed charges,1.29,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.53,38,,1.224,percent of total billed charges,38% of total billed charges,1.61,40,,14.264,percent of total billed charges,40% of total billed charges,1.29,3.43,
metoprolol Succinate 50 mg ER Tab [FMC],2567899,CDM,250,RC,,,OUTPATIENT,1,EA,3.58,2.148,,3.04,85,,2.432,Percent of total billed charges,85% of total billed charges,1.79,50,,154,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.79,50,,14.76,percent of total billed charges,50% of total billed charges,1.14,31.95,,10.976,percent of total billed charges,31.95% of total billed charges,1.14,31.95,,10.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.36,38,,1.088,percent of total billed charges,38% of total billed charges,1.43,40,,13.744,percent of total billed charges,40% of total billed charges,1.14,3.04,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,412,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,14.76,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.264,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.584,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,412,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,9.648,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,412,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,9.168,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.264,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.584,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,890,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,35.672,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,412,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,21.064,percent of total billed charges,50% of total billed charges,1.28,31.95,,12.28,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,11.168,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,412,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,21.968,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.112,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,9.192,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,412,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,17.192,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.296,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.624,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,412,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,27.112,percent of total billed charges,50% of total billed charges,1.28,31.95,,7.176,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,7.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,8.984,percent of total billed charges,40% of total billed charges,1.28,3.4,
traMADol 50 mg Tab [FMC],2567923,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,22,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,67.152,percent of total billed charges,50% of total billed charges,1.28,31.95,,4.88,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,4.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,6.112,percent of total billed charges,40% of total billed charges,1.28,3.4,
nitroglycerin 0.2 mg/hr Transderm ER Film [FMC],2567931,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,73.856,percent of total billed charges,50% of total billed charges,1.92,31.95,,9.072,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,9.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,11.36,percent of total billed charges,40% of total billed charges,1.92,5.1,
nitroglycerin 0.2 mg/hr Transderm ER Film [FMC],2567931,CDM,250,RC,,,OUTPATIENT,1,EA,6.18,3.708,,5.25,85,,4.2,Percent of total billed charges,85% of total billed charges,3.09,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.09,50,,47.064,percent of total billed charges,50% of total billed charges,1.97,31.95,,11.336,percent of total billed charges,31.95% of total billed charges,1.97,31.95,,11.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.35,38,,1.88,percent of total billed charges,38% of total billed charges,2.47,40,,14.192,percent of total billed charges,40% of total billed charges,1.97,5.25,
nitroglycerin 0.2 mg/hr ER [FMC],2567931,CDM,250,RC,,,OUTPATIENT,1,EA,8.44,5.064,,7.17,85,,5.736,Percent of total billed charges,85% of total billed charges,4.22,50,,102.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.22,50,,71.272,percent of total billed charges,50% of total billed charges,2.7,31.95,,9.72,percent of total billed charges,31.95% of total billed charges,2.7,31.95,,9.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.21,38,,2.568,percent of total billed charges,38% of total billed charges,3.38,40,,12.168,percent of total billed charges,40% of total billed charges,2.7,7.17,
nitroglycerin 0.2 mg/hr ER [FMC],2567931,CDM,250,RC,,,OUTPATIENT,1,EA,6.18,3.708,,5.25,85,,4.2,Percent of total billed charges,85% of total billed charges,3.09,50,,25.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.09,50,,68.408,percent of total billed charges,50% of total billed charges,1.97,31.95,,5.784,percent of total billed charges,31.95% of total billed charges,1.97,31.95,,5.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.35,38,,1.88,percent of total billed charges,38% of total billed charges,2.47,40,,7.24,percent of total billed charges,40% of total billed charges,1.97,5.25,
traZODone 50 mg Tab [FMC],2567980,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,72.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,21.256,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.24,percent of total billed charges,40% of total billed charges,0.96,2.55,
traZODone 50 mg Tab [FMC],2567980,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,9.912,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.24,percent of total billed charges,40% of total billed charges,0.96,2.55,
traZODone 50 mg Tab [FMC],2567980,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,168.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,9.912,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.104,percent of total billed charges,40% of total billed charges,0.96,2.55,
traZODone 50 mg Tab [FMC],2567980,CDM,250,RC,,,OUTPATIENT,1,EA,3.49,2.094,,2.97,85,,2.376,Percent of total billed charges,85% of total billed charges,1.75,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.75,50,,14.912,percent of total billed charges,50% of total billed charges,1.12,31.95,,0.984,percent of total billed charges,31.95% of total billed charges,1.12,31.95,,0.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.33,38,,1.064,percent of total billed charges,38% of total billed charges,1.4,40,,1.232,percent of total billed charges,40% of total billed charges,1.12,2.97,
traZODone 50 mg Tab [FMC],2567980,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,103.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.92,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.792,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.496,percent of total billed charges,40% of total billed charges,0.96,2.55,
traZODone 50 mg Tab [FMC],2567980,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.32,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.512,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.144,percent of total billed charges,40% of total billed charges,0.96,2.55,
traZODone 50 mg Tab [FMC],2567980,CDM,250,RC,,,OUTPATIENT,1,EA,3.49,2.094,,2.97,85,,2.376,Percent of total billed charges,85% of total billed charges,1.75,50,,70,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.75,50,,13.312,percent of total billed charges,50% of total billed charges,1.12,31.95,,43.144,percent of total billed charges,31.95% of total billed charges,1.12,31.95,,43.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.33,38,,1.064,percent of total billed charges,38% of total billed charges,1.4,40,,54.016,percent of total billed charges,40% of total billed charges,1.12,2.97,
triamcinolone topical 0.1% Cream 15 gm [FMC],2568004,CDM,250,RC,,,OUTPATIENT,15,EA,18.95,11.37,,16.11,85,,12.888,Percent of total billed charges,85% of total billed charges,9.48,50,,100,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.48,50,,2.4,percent of total billed charges,50% of total billed charges,6.05,31.95,,43.144,percent of total billed charges,31.95% of total billed charges,6.05,31.95,,43.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.2,38,,5.76,percent of total billed charges,38% of total billed charges,7.58,40,,54.016,percent of total billed charges,40% of total billed charges,6.05,16.11,
triamcinolone topical 0.1% Cream 15 gm [FMC],2568004,CDM,250,RC,,,OUTPATIENT,15,EA,18.14,10.884,,15.42,85,,12.336,Percent of total billed charges,85% of total billed charges,9.07,50,,112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.07,50,,1.616,percent of total billed charges,50% of total billed charges,5.8,31.95,,16.2,percent of total billed charges,31.95% of total billed charges,5.8,31.95,,16.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.89,38,,5.512,percent of total billed charges,38% of total billed charges,7.26,40,,20.28,percent of total billed charges,40% of total billed charges,5.8,15.42,
triamcinolone topical 0.1% Cream 15 gm [FMC],2568004,CDM,250,RC,,,OUTPATIENT,15,EA,17.91,10.746,,15.22,85,,12.176,Percent of total billed charges,85% of total billed charges,8.96,50,,98.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.96,50,,1.616,percent of total billed charges,50% of total billed charges,5.72,31.95,,3.104,percent of total billed charges,31.95% of total billed charges,5.72,31.95,,3.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.81,38,,5.448,percent of total billed charges,38% of total billed charges,7.16,40,,3.88,percent of total billed charges,40% of total billed charges,5.72,15.22,
triazolam 0.25 mg Tab [FMC],2568038,CDM,250,RC,,,OUTPATIENT,1,EA,8.91,5.346,,7.57,85,,6.056,Percent of total billed charges,85% of total billed charges,4.46,50,,194.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.46,50,,1.2,percent of total billed charges,50% of total billed charges,2.85,31.95,,1.96,percent of total billed charges,31.95% of total billed charges,2.85,31.95,,1.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.39,38,,2.712,percent of total billed charges,38% of total billed charges,3.56,40,,2.448,percent of total billed charges,40% of total billed charges,2.85,7.57,
triazolam 0.25 mg Tab [FMC],2568038,CDM,250,RC,,,OUTPATIENT,1,EA,10.36,6.216,,8.81,85,,7.048,Percent of total billed charges,85% of total billed charges,5.18,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.18,50,,1.2,percent of total billed charges,50% of total billed charges,3.31,31.95,,24.92,percent of total billed charges,31.95% of total billed charges,3.31,31.95,,24.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.94,38,,3.152,percent of total billed charges,38% of total billed charges,4.14,40,,31.2,percent of total billed charges,40% of total billed charges,3.31,8.81,
triazolam 0.25 mg Tab [FMC],2568038,CDM,250,RC,,,OUTPATIENT,1,EA,18.21,10.926,,15.48,85,,12.384,Percent of total billed charges,85% of total billed charges,9.11,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.11,50,,1.2,percent of total billed charges,50% of total billed charges,5.82,31.95,,1.072,percent of total billed charges,31.95% of total billed charges,5.82,31.95,,1.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.92,38,,5.536,percent of total billed charges,38% of total billed charges,7.28,40,,1.344,percent of total billed charges,40% of total billed charges,5.82,15.48,
triamcinolone Top 0.1% Paste [FMC],2568053,CDM,250,RC,,,OUTPATIENT,5,EA,261.92,157.152,,222.63,85,,178.104,Percent of total billed charges,85% of total billed charges,130.96,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,130.96,50,,5.8,percent of total billed charges,50% of total billed charges,83.68,31.95,,0.968,percent of total billed charges,31.95% of total billed charges,83.68,31.95,,0.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,99.53,38,,79.624,percent of total billed charges,38% of total billed charges,104.77,40,,1.208,percent of total billed charges,40% of total billed charges,83.68,222.63,
triamcinolone Top 0.1% Paste [FMC],2568053,CDM,250,RC,,,OUTPATIENT,5,EA,269.85,161.91,,229.37,85,,183.496,Percent of total billed charges,85% of total billed charges,134.93,50,,186,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,134.93,50,,1.2,percent of total billed charges,50% of total billed charges,86.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,86.22,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.54,38,,82.032,percent of total billed charges,38% of total billed charges,107.94,40,,0.96,percent of total billed charges,40% of total billed charges,86.22,229.37,
oxcarbazepine 150 mg Tab [FMC],2568111,CDM,250,RC,,,OUTPATIENT,1,EA,4.9,2.94,,4.17,85,,3.336,Percent of total billed charges,85% of total billed charges,2.45,50,,4000,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.45,50,,1.2,percent of total billed charges,50% of total billed charges,1.57,31.95,,3.504,percent of total billed charges,31.95% of total billed charges,1.57,31.95,,3.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.86,38,,1.488,percent of total billed charges,38% of total billed charges,1.96,40,,4.384,percent of total billed charges,40% of total billed charges,1.57,4.17,
oxcarbazepine 150 mg Tab [FMC],2568111,CDM,250,RC,,,OUTPATIENT,1,EA,4.96,2.976,,4.22,85,,3.376,Percent of total billed charges,85% of total billed charges,2.48,50,,186,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.48,50,,1.2,percent of total billed charges,50% of total billed charges,1.58,31.95,,3.504,percent of total billed charges,31.95% of total billed charges,1.58,31.95,,3.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.88,38,,1.504,percent of total billed charges,38% of total billed charges,1.98,40,,4.384,percent of total billed charges,40% of total billed charges,1.58,4.22,
oxcarbazepine 150 mg Tab [FMC],2568111,CDM,250,RC,,,OUTPATIENT,1,EA,4.67,2.802,,3.97,85,,3.176,Percent of total billed charges,85% of total billed charges,2.34,50,,352.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.34,50,,1.2,percent of total billed charges,50% of total billed charges,1.49,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,1.49,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.77,38,,1.416,percent of total billed charges,38% of total billed charges,1.87,40,,4.384,percent of total billed charges,40% of total billed charges,1.49,3.97,
oxcarbazepine 150 mg Tab [FMC],2568111,CDM,250,RC,,,OUTPATIENT,1,EA,4.9,2.94,,4.17,85,,3.336,Percent of total billed charges,85% of total billed charges,2.45,50,,574.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.45,50,,2.568,percent of total billed charges,50% of total billed charges,1.57,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,1.57,31.95,,3.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.86,38,,1.488,percent of total billed charges,38% of total billed charges,1.96,40,,4.384,percent of total billed charges,40% of total billed charges,1.57,4.17,
tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [FMC],2568210,CDM,250,RC,,,OUTPATIENT,0.1,ML,36.74,22.044,,31.23,85,,24.984,Percent of total billed charges,85% of total billed charges,18.37,50,,322.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.37,50,,2.496,percent of total billed charges,50% of total billed charges,11.74,31.95,,6.4,percent of total billed charges,31.95% of total billed charges,11.74,31.95,,6.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.96,38,,11.168,percent of total billed charges,38% of total billed charges,14.7,40,,8.008,percent of total billed charges,40% of total billed charges,11.74,31.23,
tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [FMC],2568210,CDM,250,RC,,,OUTPATIENT,0.1,ML,34.65,20.79,,29.45,85,,23.56,Percent of total billed charges,85% of total billed charges,17.33,50,,1558.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.33,50,,2.72,percent of total billed charges,50% of total billed charges,11.07,31.95,,4.92,percent of total billed charges,31.95% of total billed charges,11.07,31.95,,4.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.17,38,,10.536,percent of total billed charges,38% of total billed charges,13.86,40,,6.16,percent of total billed charges,40% of total billed charges,11.07,29.45,
tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [FMC],2568210,CDM,250,RC,,,OUTPATIENT,0.1,ML,20.29,12.174,,17.25,85,,13.8,Percent of total billed charges,85% of total billed charges,10.15,50,,368.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.15,50,,2.72,percent of total billed charges,50% of total billed charges,6.48,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,6.48,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.71,38,,6.168,percent of total billed charges,38% of total billed charges,8.12,40,,3.84,percent of total billed charges,40% of total billed charges,6.48,17.25,
tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [FMC],2568210,CDM,250,RC,,,OUTPATIENT,0.1,ML,25.84,15.504,,21.96,85,,17.568,Percent of total billed charges,85% of total billed charges,12.92,50,,442.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.92,50,,2.72,percent of total billed charges,50% of total billed charges,8.26,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,8.26,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.82,38,,7.856,percent of total billed charges,38% of total billed charges,10.34,40,,8.168,percent of total billed charges,40% of total billed charges,8.26,21.96,
witch hazel topical 50% Pad [FMC],2568228,CDM,250,RC,,,OUTPATIENT,1,EA,9.75,5.85,,8.29,85,,6.632,Percent of total billed charges,85% of total billed charges,4.88,50,,116.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.88,50,,518.44,percent of total billed charges,50% of total billed charges,3.12,31.95,,6.784,percent of total billed charges,31.95% of total billed charges,3.12,31.95,,6.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.71,38,,2.968,percent of total billed charges,38% of total billed charges,3.9,40,,8.496,percent of total billed charges,40% of total billed charges,3.12,8.29,
calcium carbonate 500mg Chewtab [FMC],2568236,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,518.44,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.784,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,8.488,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium carbonate 500mg Chewtab [FMC],2568236,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.648,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.6,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium carbonate 500mg Chewtab [FMC],2568236,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,20.248,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.528,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium carbonate 500mg Chewtab [FMC],2568236,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,43.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.928,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.072,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.848,percent of total billed charges,40% of total billed charges,0.96,2.55,
"chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 473 mL [FMC]",2568251,CDM,250,RC,,,OUTPATIENT,5,ML,10.58,6.348,,8.99,85,,7.192,Percent of total billed charges,85% of total billed charges,5.29,50,,45.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.29,50,,12.976,percent of total billed charges,50% of total billed charges,3.38,31.95,,4.28,percent of total billed charges,31.95% of total billed charges,3.38,31.95,,4.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.02,38,,3.216,percent of total billed charges,38% of total billed charges,4.23,40,,5.36,percent of total billed charges,40% of total billed charges,3.38,8.99,
"chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 473 mL [FMC]",2568251,CDM,250,RC,,,OUTPATIENT,5,ML,10.58,6.348,,8.99,85,,7.192,Percent of total billed charges,85% of total billed charges,5.29,50,,82,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.29,50,,1.2,percent of total billed charges,50% of total billed charges,3.38,31.95,,1.472,percent of total billed charges,31.95% of total billed charges,3.38,31.95,,1.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.02,38,,3.216,percent of total billed charges,38% of total billed charges,4.23,40,,1.84,percent of total billed charges,40% of total billed charges,3.38,8.99,
"chlorpheniramine-HYDROcodone 8 mg-10 mg/5 mL Oral Susp, ER 473 mL [FMC]",2568251,CDM,250,RC,,,OUTPATIENT,5,ML,10.87,6.522,,9.24,85,,7.392,Percent of total billed charges,85% of total billed charges,5.44,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.44,50,,1.2,percent of total billed charges,50% of total billed charges,3.47,31.95,,2.992,percent of total billed charges,31.95% of total billed charges,3.47,31.95,,2.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.13,38,,3.304,percent of total billed charges,38% of total billed charges,4.35,40,,3.744,percent of total billed charges,40% of total billed charges,3.47,9.24,
acetaminophen 650 mg/ 20.3ml Oral Liq [FMC],2568269,CDM,250,RC,,,OUTPATIENT,20.3,ML,7.93,4.758,,6.74,85,,5.392,Percent of total billed charges,85% of total billed charges,3.97,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.97,50,,1.2,percent of total billed charges,50% of total billed charges,2.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.53,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.01,38,,2.408,percent of total billed charges,38% of total billed charges,3.17,40,,0.96,percent of total billed charges,40% of total billed charges,2.53,6.74,
acetaminophen 650 mg/ 20.3ml Oral Liq [FMC],2568269,CDM,250,RC,,,OUTPATIENT,20.3,ML,9.25,5.55,,7.86,85,,6.288,Percent of total billed charges,85% of total billed charges,4.63,50,,255.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.63,50,,351.136,percent of total billed charges,50% of total billed charges,2.96,31.95,,2.392,percent of total billed charges,31.95% of total billed charges,2.96,31.95,,2.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.52,38,,2.816,percent of total billed charges,38% of total billed charges,3.7,40,,3,percent of total billed charges,40% of total billed charges,2.96,7.86,
acetaminophen 650 mg/ 20.3ml Oral Liq [FMC],2568269,CDM,250,RC,,,OUTPATIENT,20.3,ML,8.35,5.01,,7.1,85,,5.68,Percent of total billed charges,85% of total billed charges,4.18,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.18,50,,5.656,percent of total billed charges,50% of total billed charges,2.67,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,2.67,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.17,38,,2.536,percent of total billed charges,38% of total billed charges,3.34,40,,1.92,percent of total billed charges,40% of total billed charges,2.67,7.1,
acetaminophen 325 mg Tab [FMC],2568277,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.224,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen 325 mg Tab [FMC],2568277,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,22.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.968,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen 325 mg Tab [FMC],2568277,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.048,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen 325 mg Tab [FMC],2568277,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.44,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.336,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.424,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen-codeine 300mg-30mg Tab [FMC],2568285,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,10.448,percent of total billed charges,50% of total billed charges,1.28,31.95,,4.336,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,4.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,5.432,percent of total billed charges,40% of total billed charges,1.28,3.4,
acetaminophen 500 mg Tab [FMC],2568293,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.44,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.968,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen 500 mg Tab [FMC],2568293,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.448,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.448,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,8.072,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen 500 mg Tab [FMC],2568293,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12.416,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.336,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.432,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen 500 mg Tab [FMC],2568293,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12.496,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.872,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.848,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaminophen-tramadol 325 mg-37.5 mg Tab [FMC],2568376,CDM,250,RC,,,OUTPATIENT,1,EA,8.1,4.86,,6.89,85,,5.512,Percent of total billed charges,85% of total billed charges,4.05,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.05,50,,8.296,percent of total billed charges,50% of total billed charges,2.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.08,38,,2.464,percent of total billed charges,38% of total billed charges,3.24,40,,0.96,percent of total billed charges,40% of total billed charges,2.59,6.89,
acetaminophen-tramadol 325 mg-37.5 mg Tab [FMC],2568376,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
acetaminophen-tramadol 325 mg-37.5 mg Tab [FMC],2568376,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.352,percent of total billed charges,50% of total billed charges,1.28,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.024,percent of total billed charges,40% of total billed charges,1.28,3.4,
ampicillin-sulbactam 1 g-0.5 g Inj [FMC],2568384,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,25.14,15.084,,21.37,85,,17.096,Percent of total billed charges,85% of total billed charges,3.09,136.6,,10.72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.84,35.15,,2.336,fee schedule,35.15% of LA custom fee schedule,8.03,31.95,,2.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.55,38,,7.64,percent of total billed charges,38% of total billed charges,8.03,31.95,,2.928,Fee Schedule,31.95% of LA custom fee schedule,3.09,21.37,
ampicillin-sulbactam 1 g-0.5 g Inj [FMC],2568384,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,30.08,18.048,,25.57,85,,20.456,Percent of total billed charges,85% of total billed charges,3.09,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,10.57,35.15,,1.744,fee schedule,35.15% of LA custom fee schedule,9.61,31.95,,1.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.43,38,,9.144,percent of total billed charges,38% of total billed charges,9.61,31.95,,2.184,Fee Schedule,31.95% of LA custom fee schedule,3.09,25.57,
ampicillin-sulbactam 1 g-0.5 g Inj [FMC],2568384,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,21.45,12.87,,18.23,85,,14.584,Percent of total billed charges,85% of total billed charges,3.09,136.6,,37.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,289.8,fee schedule,136.60% of BCBS custom fee schedule,7.54,35.15,,2.64,fee schedule,35.15% of LA custom fee schedule,6.85,31.95,,2.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.15,38,,6.52,percent of total billed charges,38% of total billed charges,6.85,31.95,,3.304,Fee Schedule,31.95% of LA custom fee schedule,3.09,18.23,
ampicillin-sulbactam 2 g-1 g Inj [FMC],2568392,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,30.06,18.036,,25.55,85,,20.44,Percent of total billed charges,85% of total billed charges,3.09,136.6,,36.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,427.832,fee schedule,136.60% of BCBS custom fee schedule,10.57,35.15,,2.256,fee schedule,35.15% of LA custom fee schedule,9.6,31.95,,2.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.42,38,,9.136,percent of total billed charges,38% of total billed charges,9.6,31.95,,2.824,Fee Schedule,31.95% of LA custom fee schedule,3.09,25.55,
ampicillin-sulbactam 2 g-1 g Inj [FMC],2568392,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,47.45,28.47,,40.33,85,,32.264,Percent of total billed charges,85% of total billed charges,3.09,136.6,,36.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,5.408,fee schedule,136.60% of BCBS custom fee schedule,16.68,35.15,,2.648,fee schedule,35.15% of LA custom fee schedule,15.16,31.95,,2.648,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.03,38,,14.424,percent of total billed charges,38% of total billed charges,15.16,31.95,,3.312,Fee Schedule,31.95% of LA custom fee schedule,3.09,40.33,
ampicillin-sulbactam 2 g-1 g Inj [FMC],2568392,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,56.79,34.074,,48.27,85,,38.616,Percent of total billed charges,85% of total billed charges,3.09,136.6,,36.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,3.528,fee schedule,136.60% of BCBS custom fee schedule,19.96,35.15,,2.64,fee schedule,35.15% of LA custom fee schedule,18.14,31.95,,2.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,21.58,38,,17.264,percent of total billed charges,38% of total billed charges,18.14,31.95,,3.312,Fee Schedule,31.95% of LA custom fee schedule,3.09,48.27,
ampicillin-sulbactam 2 g-1 g Inj [FMC],2568392,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,31.86,19.116,,27.08,85,,21.664,Percent of total billed charges,85% of total billed charges,3.09,136.6,,29.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,5.84,fee schedule,136.60% of BCBS custom fee schedule,11.2,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,10.18,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.11,38,,9.688,percent of total billed charges,38% of total billed charges,10.18,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,3.09,27.08,
ampicillin-sulbactam 2 g-1 g Inj [FMC],2568392,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,49.95,29.97,,42.46,85,,33.968,Percent of total billed charges,85% of total billed charges,3.09,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,1.352,fee schedule,136.60% of BCBS custom fee schedule,17.56,35.15,,2.888,fee schedule,35.15% of LA custom fee schedule,15.96,31.95,,2.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.98,38,,15.184,percent of total billed charges,38% of total billed charges,15.96,31.95,,3.616,Fee Schedule,31.95% of LA custom fee schedule,3.09,42.46,
ampicillin-sulbactam 2 g-1 g Inj [FMC],2568392,CDM,250,RC,J0295,HCPCS,OUTPATIENT,1,EA,29.72,17.832,,25.26,85,,20.208,Percent of total billed charges,85% of total billed charges,3.09,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.09,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,10.45,35.15,,1.128,fee schedule,35.15% of LA custom fee schedule,9.5,31.95,,35.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.29,38,,9.032,percent of total billed charges,38% of total billed charges,9.5,31.95,,1.024,Fee Schedule,31.95% of LA custom fee schedule,3.09,25.26,
moexipril 7.5 mg Tab [FMC],2568418,CDM,250,RC,,,OUTPATIENT,1,EA,10.15,6.09,,8.63,85,,6.904,Percent of total billed charges,85% of total billed charges,5.08,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.08,50,,18.824,percent of total billed charges,50% of total billed charges,3.24,31.95,,7.024,percent of total billed charges,31.95% of total billed charges,3.24,31.95,,7.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.86,38,,3.088,percent of total billed charges,38% of total billed charges,4.06,40,,8.792,percent of total billed charges,40% of total billed charges,3.24,8.63,
moexipril 7.5 mg Tab [FMC],2568418,CDM,250,RC,,,OUTPATIENT,1,EA,4.51,2.706,,3.83,85,,3.064,Percent of total billed charges,85% of total billed charges,2.26,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.26,50,,14.088,percent of total billed charges,50% of total billed charges,1.44,31.95,,7.024,percent of total billed charges,31.95% of total billed charges,1.44,31.95,,7.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.71,38,,1.368,percent of total billed charges,38% of total billed charges,1.8,40,,8.792,percent of total billed charges,40% of total billed charges,1.44,3.83,
bethanechol 25 mg Tab [FMC],2568434,CDM,250,RC,,,OUTPATIENT,1,EA,5.8,3.48,,4.93,85,,3.944,Percent of total billed charges,85% of total billed charges,2.9,50,,28.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.9,50,,1.2,percent of total billed charges,50% of total billed charges,1.85,31.95,,116.712,percent of total billed charges,31.95% of total billed charges,1.85,31.95,,116.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.2,38,,1.76,percent of total billed charges,38% of total billed charges,2.32,40,,146.12,percent of total billed charges,40% of total billed charges,1.85,4.93,
bethanechol 25 mg Tab [FMC],2568434,CDM,250,RC,,,OUTPATIENT,1,EA,8.68,5.208,,7.38,85,,5.904,Percent of total billed charges,85% of total billed charges,4.34,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.34,50,,1.2,percent of total billed charges,50% of total billed charges,2.77,31.95,,116.712,percent of total billed charges,31.95% of total billed charges,2.77,31.95,,116.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.3,38,,2.64,percent of total billed charges,38% of total billed charges,3.47,40,,146.12,percent of total billed charges,40% of total billed charges,2.77,7.38,
bethanechol 25 mg Tab [FMC],2568434,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,260,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,9.88,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,9.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,12.368,percent of total billed charges,40% of total billed charges,0.96,2.55,
bethanechol 25 mg Tab [FMC],2568434,CDM,250,RC,,,OUTPATIENT,1,EA,8.68,5.208,,7.38,85,,5.904,Percent of total billed charges,85% of total billed charges,4.34,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.34,50,,37.44,percent of total billed charges,50% of total billed charges,2.77,31.95,,1.344,percent of total billed charges,31.95% of total billed charges,2.77,31.95,,1.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.3,38,,2.64,percent of total billed charges,38% of total billed charges,3.47,40,,1.68,percent of total billed charges,40% of total billed charges,2.77,7.38,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,17.15,10.29,,14.58,85,,11.664,Percent of total billed charges,85% of total billed charges,3.14,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,37.024,fee schedule,136.60% of BCBS custom fee schedule,6.03,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,5.48,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.52,38,,5.216,percent of total billed charges,38% of total billed charges,5.48,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,3.14,14.58,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,13.8,8.28,,11.73,85,,9.384,Percent of total billed charges,85% of total billed charges,3.14,136.6,,7.648,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,40.304,fee schedule,136.60% of BCBS custom fee schedule,4.85,35.15,,1.616,fee schedule,35.15% of LA custom fee schedule,4.41,31.95,,1.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.24,38,,4.192,percent of total billed charges,38% of total billed charges,4.41,31.95,,2.016,Fee Schedule,31.95% of LA custom fee schedule,3.14,11.73,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,62.56,37.536,,53.18,85,,42.544,Percent of total billed charges,85% of total billed charges,3.14,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,15.224,fee schedule,136.60% of BCBS custom fee schedule,21.99,35.15,,147.784,fee schedule,35.15% of LA custom fee schedule,19.99,31.95,,35.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,23.77,38,,19.016,percent of total billed charges,38% of total billed charges,19.99,31.95,,134.336,Fee Schedule,31.95% of LA custom fee schedule,3.14,53.18,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,52.81,31.686,,44.89,85,,35.912,Percent of total billed charges,85% of total billed charges,3.14,136.6,,26.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,18.56,35.15,,153.944,fee schedule,35.15% of LA custom fee schedule,16.87,31.95,,35.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.07,38,,16.056,percent of total billed charges,38% of total billed charges,16.87,31.95,,139.928,Fee Schedule,31.95% of LA custom fee schedule,3.14,44.89,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,13.07,7.842,,11.11,85,,8.888,Percent of total billed charges,85% of total billed charges,3.14,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,265.2,fee schedule,136.60% of BCBS custom fee schedule,4.59,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,4.18,31.95,,35.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.97,38,,3.976,percent of total billed charges,38% of total billed charges,4.18,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,3.14,11.11,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,23.36,14.016,,19.86,85,,15.888,Percent of total billed charges,85% of total billed charges,3.14,136.6,,168.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,850.2,fee schedule,136.60% of BCBS custom fee schedule,8.21,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,7.46,31.95,,36.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.88,38,,7.104,percent of total billed charges,38% of total billed charges,7.46,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,3.14,19.86,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,19.6,11.76,,16.66,85,,13.328,Percent of total billed charges,85% of total billed charges,3.14,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,6.89,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,6.26,31.95,,36.296,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.45,38,,5.96,percent of total billed charges,38% of total billed charges,6.26,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,3.14,16.66,
vancomycin 1 g IV Inj [FMC],2568558,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,3.14,136.6,,168.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,7.48,31.95,,37.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,3.14,19.89,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,31.36,18.816,,26.66,85,,21.328,Percent of total billed charges,85% of total billed charges,3.14,136.6,,135,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,11.02,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,10.02,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.92,38,,9.536,percent of total billed charges,38% of total billed charges,10.02,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,3.14,26.66,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,31.83,19.098,,27.06,85,,21.648,Percent of total billed charges,85% of total billed charges,3.14,136.6,,21.288,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,11.19,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,10.17,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.1,38,,9.68,percent of total billed charges,38% of total billed charges,10.17,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,3.14,27.06,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,3.14,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,7.792,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,22.816,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,22.816,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,28.56,Fee Schedule,31.95% of LA custom fee schedule,3.14,10.2,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,27.3,16.38,,23.21,85,,18.568,Percent of total billed charges,85% of total billed charges,3.14,136.6,,4.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,7.792,fee schedule,136.60% of BCBS custom fee schedule,9.6,35.15,,18.232,fee schedule,35.15% of LA custom fee schedule,8.72,31.95,,18.232,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.37,38,,8.296,percent of total billed charges,38% of total billed charges,8.72,31.95,,22.832,Fee Schedule,31.95% of LA custom fee schedule,3.14,23.21,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,27.3,16.38,,23.21,85,,18.568,Percent of total billed charges,85% of total billed charges,3.14,136.6,,4.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,7.792,fee schedule,136.60% of BCBS custom fee schedule,9.6,35.15,,31.12,fee schedule,35.15% of LA custom fee schedule,8.72,31.95,,31.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.37,38,,8.296,percent of total billed charges,38% of total billed charges,8.72,31.95,,38.96,Fee Schedule,31.95% of LA custom fee schedule,3.14,23.21,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,3.14,136.6,,4.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,7.8,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,31.528,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,31.528,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,39.472,Fee Schedule,31.95% of LA custom fee schedule,3.14,10.2,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,27.3,16.38,,23.21,85,,18.568,Percent of total billed charges,85% of total billed charges,3.14,136.6,,4.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,1.304,fee schedule,136.60% of BCBS custom fee schedule,9.6,35.15,,23.256,fee schedule,35.15% of LA custom fee schedule,8.72,31.95,,23.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.37,38,,8.296,percent of total billed charges,38% of total billed charges,8.72,31.95,,29.12,Fee Schedule,31.95% of LA custom fee schedule,3.14,23.21,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,3.14,136.6,,4.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,6.936,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.016,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,4.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,5.024,Fee Schedule,31.95% of LA custom fee schedule,3.14,10.2,
vancomycin 500 mg IV Inj [FMC],2568574,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,16.03,9.618,,13.63,85,,10.904,Percent of total billed charges,85% of total billed charges,3.14,136.6,,4.008,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,4.584,fee schedule,136.60% of BCBS custom fee schedule,5.63,35.15,,4.016,fee schedule,35.15% of LA custom fee schedule,5.12,31.95,,4.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.09,38,,4.872,percent of total billed charges,38% of total billed charges,5.12,31.95,,5.024,Fee Schedule,31.95% of LA custom fee schedule,3.14,13.63,
vasopressin 20 units/mL Inj Sol [FMC],2568665,CDM,250,RC,,,OUTPATIENT,1,ML,828.27,496.962,,704.03,85,,563.224,Percent of total billed charges,85% of total billed charges,414.14,50,,94.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,414.14,50,,6.184,percent of total billed charges,50% of total billed charges,264.63,31.95,,1.344,percent of total billed charges,31.95% of total billed charges,264.63,31.95,,1.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,314.74,38,,251.792,percent of total billed charges,38% of total billed charges,331.31,40,,1.68,percent of total billed charges,40% of total billed charges,264.63,704.03,
vasopressin 20 units/mL Inj Sol [FMC],2568665,CDM,250,RC,,,OUTPATIENT,1,ML,89.7,53.82,,76.25,85,,61,Percent of total billed charges,85% of total billed charges,44.85,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.85,50,,4.128,percent of total billed charges,50% of total billed charges,28.66,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,28.66,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.09,38,,27.272,percent of total billed charges,38% of total billed charges,35.88,40,,1.28,percent of total billed charges,40% of total billed charges,28.66,76.25,
verapamil 180 mg ER Tab [FMC],2568699,CDM,250,RC,,,OUTPATIENT,1,EA,4.68,2.808,,3.98,85,,3.184,Percent of total billed charges,85% of total billed charges,2.34,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.34,50,,3.976,percent of total billed charges,50% of total billed charges,1.5,31.95,,1.584,percent of total billed charges,31.95% of total billed charges,1.5,31.95,,1.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.78,38,,1.424,percent of total billed charges,38% of total billed charges,1.87,40,,1.984,percent of total billed charges,40% of total billed charges,1.5,3.98,
verapamil 180 mg ER Tab [FMC],2568699,CDM,250,RC,,,OUTPATIENT,1,EA,8.1,4.86,,6.89,85,,5.512,Percent of total billed charges,85% of total billed charges,4.05,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.05,50,,3.976,percent of total billed charges,50% of total billed charges,2.59,31.95,,1.584,percent of total billed charges,31.95% of total billed charges,2.59,31.95,,1.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.08,38,,2.464,percent of total billed charges,38% of total billed charges,3.24,40,,1.984,percent of total billed charges,40% of total billed charges,2.59,6.89,
verapamil 2.5 mg/mL Inj 2 mL Sol [FMC],2568723,CDM,250,RC,,,OUTPATIENT,1,ML,49.47,29.682,,42.05,85,,33.64,Percent of total billed charges,85% of total billed charges,24.74,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.74,50,,37.64,percent of total billed charges,50% of total billed charges,15.81,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,15.81,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.8,38,,15.04,percent of total billed charges,38% of total billed charges,19.79,40,,1.152,percent of total billed charges,40% of total billed charges,15.81,42.05,
verapamil 2.5 mg/mL Inj 2 mL Sol [FMC],2568723,CDM,250,RC,,,OUTPATIENT,1,ML,49.11,29.466,,41.74,85,,33.392,Percent of total billed charges,85% of total billed charges,24.56,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.56,50,,35.88,percent of total billed charges,50% of total billed charges,15.69,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,15.69,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.66,38,,14.928,percent of total billed charges,38% of total billed charges,19.64,40,,1.112,percent of total billed charges,40% of total billed charges,15.69,41.74,
verapamil 2.5 mg/mL Inj 2 mL Sol [FMC],2568723,CDM,250,RC,,,OUTPATIENT,1,ML,116.19,69.714,,98.76,85,,79.008,Percent of total billed charges,85% of total billed charges,58.1,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,58.1,50,,35.88,percent of total billed charges,50% of total billed charges,37.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,37.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.15,38,,35.32,percent of total billed charges,38% of total billed charges,46.48,40,,0.96,percent of total billed charges,40% of total billed charges,37.12,98.76,
verapamil 2.5 mg/mL Inj 2 mL Sol [FMC],2568723,CDM,250,RC,,,OUTPATIENT,1,ML,20.3,12.18,,17.26,85,,13.808,Percent of total billed charges,85% of total billed charges,10.15,50,,405,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.15,50,,2.6,percent of total billed charges,50% of total billed charges,6.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.71,38,,6.168,percent of total billed charges,38% of total billed charges,8.12,40,,0.96,percent of total billed charges,40% of total billed charges,6.49,17.26,
verapamil 2.5 mg/mL Inj 2 mL Sol [FMC],2568723,CDM,250,RC,,,OUTPATIENT,1,ML,20.31,12.186,,17.26,85,,13.808,Percent of total billed charges,85% of total billed charges,10.16,50,,3.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.16,50,,2.6,percent of total billed charges,50% of total billed charges,6.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.72,38,,6.176,percent of total billed charges,38% of total billed charges,8.12,40,,0.96,percent of total billed charges,40% of total billed charges,6.49,17.26,
verapamil 80 mg Tab [FMC],2568731,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.392,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.352,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
verapamil 80 mg Tab [FMC],2568731,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,12.168,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,12.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,15.232,percent of total billed charges,40% of total billed charges,0.96,2.55,
lidocaine topical viscous (oral)2% Sol 15 mL [FMC],2568897,CDM,250,RC,,,OUTPATIENT,15,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,2.6,percent of total billed charges,50% of total billed charges,3.83,31.95,,11.52,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,11.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,14.424,percent of total billed charges,40% of total billed charges,3.83,10.2,
lidocaine topical viscous (oral)2% Sol 15 mL [FMC],2568897,CDM,250,RC,,,OUTPATIENT,15,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,9.392,percent of total billed charges,50% of total billed charges,3.83,31.95,,7.568,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,6.88,percent of total billed charges,40% of total billed charges,3.83,10.2,
lidocaine topical viscous (oral)2% Sol 15 mL [FMC],2568897,CDM,250,RC,,,OUTPATIENT,15,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,3.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,9.464,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,8.6,percent of total billed charges,40% of total billed charges,3.83,10.2,
lidocaine topical viscous (oral)2% Sol 15 mL [FMC],2568897,CDM,250,RC,,,OUTPATIENT,15,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,22.12,percent of total billed charges,50% of total billed charges,3.83,31.95,,13.256,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,12.048,percent of total billed charges,40% of total billed charges,3.83,10.2,
lidocaine topical viscous (oral)2% Sol 15 mL [FMC],2568897,CDM,250,RC,,,OUTPATIENT,15,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,33.184,percent of total billed charges,50% of total billed charges,3.83,31.95,,13.256,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,12.048,percent of total billed charges,40% of total billed charges,3.83,10.2,
lidocaine topical viscous (oral)2% Sol 15 mL [FMC],2568897,CDM,250,RC,,,OUTPATIENT,15,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,10.144,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,9.224,percent of total billed charges,40% of total billed charges,3.83,10.2,
lidocaine topical viscous (oral)2% Sol 15 mL [FMC],2568897,CDM,250,RC,,,OUTPATIENT,15,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,12.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,9.72,percent of total billed charges,50% of total billed charges,3.83,31.95,,10.144,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,9.224,percent of total billed charges,40% of total billed charges,3.83,10.2,
ascorbic acid 500 mg Tab [FMC],2568947,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,29.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.064,percent of total billed charges,40% of total billed charges,0.96,2.55,
ascorbic acid 500 mg Tab [FMC],2568947,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.888,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.944,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.424,percent of total billed charges,40% of total billed charges,0.96,2.55,
ascorbic acid 500 mg Tab [FMC],2568947,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,41.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.088,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
ascorbic acid 500 mg Tab [FMC],2568947,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.736,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
pyridoxine 100mg Tab [FMC],2568988,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,26.928,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
pyridoxine 100mg Tab [FMC],2568988,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,30.488,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
colesevelam 625 mg Tab [FMC],2569010,CDM,250,RC,,,OUTPATIENT,1,EA,9.13,5.478,,7.76,85,,6.208,Percent of total billed charges,85% of total billed charges,4.57,50,,51.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.57,50,,1.2,percent of total billed charges,50% of total billed charges,2.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.47,38,,2.776,percent of total billed charges,38% of total billed charges,3.65,40,,0.96,percent of total billed charges,40% of total billed charges,2.92,7.76,
colesevelam 625 mg Tab [FMC],2569010,CDM,250,RC,,,OUTPATIENT,1,EA,12.17,7.302,,10.34,85,,8.272,Percent of total billed charges,85% of total billed charges,6.09,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.09,50,,1.2,percent of total billed charges,50% of total billed charges,3.89,31.95,,151.408,percent of total billed charges,31.95% of total billed charges,3.89,31.95,,151.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.62,38,,3.696,percent of total billed charges,38% of total billed charges,4.87,40,,189.552,percent of total billed charges,40% of total billed charges,3.89,10.34,
colesevelam 625 mg Tab,2569010,CDM,250,RC,,,OUTPATIENT,1,EA,12.98,7.788,,11.03,85,,8.824,Percent of total billed charges,85% of total billed charges,6.49,50,,3.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.49,50,,12.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,136.112,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,136.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.93,38,,3.944,percent of total billed charges,38% of total billed charges,5.19,40,,170.4,percent of total billed charges,40% of total billed charges,4.15,11.03,
buPROPion 100 mg/12 hours ER [FMC],2569028,CDM,250,RC,,,OUTPATIENT,1,EA,5.49,3.294,,4.67,85,,3.736,Percent of total billed charges,85% of total billed charges,2.75,50,,71.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.75,50,,13.408,percent of total billed charges,50% of total billed charges,1.75,31.95,,136.024,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,136.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.09,38,,1.672,percent of total billed charges,38% of total billed charges,2.2,40,,170.288,percent of total billed charges,40% of total billed charges,1.75,4.67,
buPROPion 100 mg/12 hours ER [FMC],2569028,CDM,250,RC,,,OUTPATIENT,1,EA,5.41,3.246,,4.6,85,,3.68,Percent of total billed charges,85% of total billed charges,2.71,50,,17.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.71,50,,15.344,percent of total billed charges,50% of total billed charges,1.73,31.95,,136.264,percent of total billed charges,31.95% of total billed charges,1.73,31.95,,136.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.06,38,,1.648,percent of total billed charges,38% of total billed charges,2.16,40,,170.592,percent of total billed charges,40% of total billed charges,1.73,4.6,
buPROPion 100 mg/12 hours ER [FMC],2569028,CDM,250,RC,,,OUTPATIENT,1,EA,5.49,3.294,,4.67,85,,3.736,Percent of total billed charges,85% of total billed charges,2.75,50,,3.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.75,50,,19.576,percent of total billed charges,50% of total billed charges,1.75,31.95,,5.288,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,5.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.09,38,,1.672,percent of total billed charges,38% of total billed charges,2.2,40,,6.624,percent of total billed charges,40% of total billed charges,1.75,4.67,
latanoprost Ophth 0.005% Sol [FMC],2569077,CDM,250,RC,,,OUTPATIENT,2.5,EA,308.75,185.25,,262.44,85,,209.952,Percent of total billed charges,85% of total billed charges,154.38,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,154.38,50,,19.584,percent of total billed charges,50% of total billed charges,98.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,98.65,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.33,38,,93.864,percent of total billed charges,38% of total billed charges,123.5,40,,0.96,percent of total billed charges,40% of total billed charges,98.65,262.44,
latanoprost Ophth 0.005% Sol [FMC],2569077,CDM,250,RC,,,OUTPATIENT,2.5,EA,79.24,47.544,,67.35,85,,53.88,Percent of total billed charges,85% of total billed charges,39.62,50,,168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39.62,50,,421.488,percent of total billed charges,50% of total billed charges,25.32,31.95,,6.472,percent of total billed charges,31.95% of total billed charges,25.32,31.95,,6.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.11,38,,24.088,percent of total billed charges,38% of total billed charges,31.7,40,,8.104,percent of total billed charges,40% of total billed charges,25.32,67.35,
lidocaine Top 4% 50 mL Sol [FMC],2569168,CDM,250,RC,,,OUTPATIENT,50,EA,156,93.6,,132.6,85,,106.08,Percent of total billed charges,85% of total billed charges,78,50,,117.832,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,78,50,,9.96,percent of total billed charges,50% of total billed charges,49.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,49.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,59.28,38,,47.424,percent of total billed charges,38% of total billed charges,62.4,40,,0.96,percent of total billed charges,40% of total billed charges,49.84,132.6,
lidocaine Top 4% 50 mL Sol [FMC],2569168,CDM,250,RC,,,OUTPATIENT,50,EA,51.19,30.714,,43.51,85,,34.808,Percent of total billed charges,85% of total billed charges,25.6,50,,63.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.6,50,,10.224,percent of total billed charges,50% of total billed charges,16.36,31.95,,1.192,percent of total billed charges,31.95% of total billed charges,16.36,31.95,,1.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.45,38,,15.56,percent of total billed charges,38% of total billed charges,20.48,40,,1.488,percent of total billed charges,40% of total billed charges,16.36,43.51,
lidocaine Top 4% 50 mL Sol [FMC],2569168,CDM,250,RC,,,OUTPATIENT,50,EA,210.08,126.048,,178.57,85,,142.856,Percent of total billed charges,85% of total billed charges,105.04,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.04,50,,9.472,percent of total billed charges,50% of total billed charges,67.12,31.95,,2.264,percent of total billed charges,31.95% of total billed charges,67.12,31.95,,2.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.83,38,,63.864,percent of total billed charges,38% of total billed charges,84.03,40,,2.832,percent of total billed charges,40% of total billed charges,67.12,178.57,
tiZANidine 4 mg Tab [FMC],2569192,CDM,250,RC,,,OUTPATIENT,1,EA,8.28,4.968,,7.04,85,,5.632,Percent of total billed charges,85% of total billed charges,4.14,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.14,50,,12.896,percent of total billed charges,50% of total billed charges,2.65,31.95,,1,percent of total billed charges,31.95% of total billed charges,2.65,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.15,38,,2.52,percent of total billed charges,38% of total billed charges,3.31,40,,1.248,percent of total billed charges,40% of total billed charges,2.65,7.04,
tiZANidine 4 mg Tab [FMC],2569192,CDM,250,RC,,,OUTPATIENT,1,EA,5.73,3.438,,4.87,85,,3.896,Percent of total billed charges,85% of total billed charges,2.87,50,,47.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.87,50,,4.904,percent of total billed charges,50% of total billed charges,1.83,31.95,,2.904,percent of total billed charges,31.95% of total billed charges,1.83,31.95,,2.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.18,38,,1.744,percent of total billed charges,38% of total billed charges,2.29,40,,3.64,percent of total billed charges,40% of total billed charges,1.83,4.87,
tiZANidine 4 mg Tab [FMC],2569192,CDM,250,RC,,,OUTPATIENT,1,EA,4.92,2.952,,4.18,85,,3.344,Percent of total billed charges,85% of total billed charges,2.46,50,,2.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.46,50,,95.8,percent of total billed charges,50% of total billed charges,1.57,31.95,,0.776,percent of total billed charges,31.95% of total billed charges,1.57,31.95,,0.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.87,38,,1.496,percent of total billed charges,38% of total billed charges,1.97,40,,0.968,percent of total billed charges,40% of total billed charges,1.57,4.18,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,14.5,8.7,,12.33,85,,9.864,Percent of total billed charges,85% of total billed charges,7.25,50,,226,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.25,50,,91.008,percent of total billed charges,50% of total billed charges,4.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.51,38,,4.408,percent of total billed charges,38% of total billed charges,5.8,40,,0.96,percent of total billed charges,40% of total billed charges,4.63,12.33,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,14.63,8.778,,12.44,85,,9.952,Percent of total billed charges,85% of total billed charges,7.32,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.32,50,,65.52,percent of total billed charges,50% of total billed charges,4.67,31.95,,23.264,percent of total billed charges,31.95% of total billed charges,4.67,31.95,,23.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.56,38,,4.448,percent of total billed charges,38% of total billed charges,5.85,40,,29.128,percent of total billed charges,40% of total billed charges,4.67,12.44,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,18.28,10.968,,15.54,85,,12.432,Percent of total billed charges,85% of total billed charges,9.14,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.14,50,,3.24,percent of total billed charges,50% of total billed charges,5.84,31.95,,40.704,percent of total billed charges,31.95% of total billed charges,5.84,31.95,,40.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.95,38,,5.56,percent of total billed charges,38% of total billed charges,7.31,40,,50.96,percent of total billed charges,40% of total billed charges,5.84,15.54,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,15.41,9.246,,13.1,85,,10.48,Percent of total billed charges,85% of total billed charges,7.71,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.71,50,,3.4,percent of total billed charges,50% of total billed charges,4.92,31.95,,22.224,percent of total billed charges,31.95% of total billed charges,4.92,31.95,,22.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.86,38,,4.688,percent of total billed charges,38% of total billed charges,6.16,40,,27.824,percent of total billed charges,40% of total billed charges,4.92,13.1,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,32.66,19.596,,27.76,85,,22.208,Percent of total billed charges,85% of total billed charges,16.33,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.33,50,,2.4,percent of total billed charges,50% of total billed charges,10.43,31.95,,22.432,percent of total billed charges,31.95% of total billed charges,10.43,31.95,,22.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.41,38,,9.928,percent of total billed charges,38% of total billed charges,13.06,40,,28.08,percent of total billed charges,40% of total billed charges,10.43,27.76,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,19.7,11.82,,16.75,85,,13.4,Percent of total billed charges,85% of total billed charges,9.85,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.85,50,,2.4,percent of total billed charges,50% of total billed charges,6.29,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,6.29,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.49,38,,5.992,percent of total billed charges,38% of total billed charges,7.88,40,,8.32,percent of total billed charges,40% of total billed charges,6.29,16.75,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,34.13,20.478,,29.01,85,,23.208,Percent of total billed charges,85% of total billed charges,17.07,50,,39.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.07,50,,2.4,percent of total billed charges,50% of total billed charges,10.9,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,10.9,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.97,38,,10.376,percent of total billed charges,38% of total billed charges,13.65,40,,12.48,percent of total billed charges,40% of total billed charges,10.9,29.01,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,26.42,15.852,,22.46,85,,17.968,Percent of total billed charges,85% of total billed charges,13.21,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.21,50,,4.616,percent of total billed charges,50% of total billed charges,8.44,31.95,,4.152,percent of total billed charges,31.95% of total billed charges,8.44,31.95,,4.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.04,38,,8.032,percent of total billed charges,38% of total billed charges,10.57,40,,5.2,percent of total billed charges,40% of total billed charges,8.44,22.46,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,11.7,50,,10.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.7,50,,13.184,percent of total billed charges,50% of total billed charges,7.48,31.95,,14.744,percent of total billed charges,31.95% of total billed charges,7.48,31.95,,14.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,9.36,40,,18.456,percent of total billed charges,40% of total billed charges,7.48,19.89,
rocuronium 10 mg/mL IV Sol [FMC],2569275,CDM,250,RC,,,OUTPATIENT,5,ML,22.91,13.746,,19.47,85,,15.576,Percent of total billed charges,85% of total billed charges,11.46,50,,367.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.46,50,,14.672,percent of total billed charges,50% of total billed charges,7.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.71,38,,6.968,percent of total billed charges,38% of total billed charges,9.16,40,,0.96,percent of total billed charges,40% of total billed charges,7.32,19.47,
ezetimibe 10 mg Tab [FMC],2569291,CDM,250,RC,,,OUTPATIENT,1,EA,44.85,26.91,,38.12,85,,30.496,Percent of total billed charges,85% of total billed charges,22.43,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.43,50,,14.672,percent of total billed charges,50% of total billed charges,14.33,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.33,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.04,38,,13.632,percent of total billed charges,38% of total billed charges,17.94,40,,0.96,percent of total billed charges,40% of total billed charges,14.33,38.12,
ezetimibe 10 mg Tab [FMC],2569291,CDM,250,RC,,,OUTPATIENT,1,EA,24.02,14.412,,20.42,85,,16.336,Percent of total billed charges,85% of total billed charges,12.01,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.01,50,,28.08,percent of total billed charges,50% of total billed charges,7.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.13,38,,7.304,percent of total billed charges,38% of total billed charges,9.61,40,,0.96,percent of total billed charges,40% of total billed charges,7.67,20.42,
ezetimibe 10 mg Tab [FMC],2569291,CDM,250,RC,,,OUTPATIENT,1,EA,40.29,24.174,,34.25,85,,27.4,Percent of total billed charges,85% of total billed charges,20.15,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.15,50,,30.088,percent of total billed charges,50% of total billed charges,12.87,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,12.87,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.31,38,,12.248,percent of total billed charges,38% of total billed charges,16.12,40,,0.96,percent of total billed charges,40% of total billed charges,12.87,34.25,
ezetimibe 10 mg Tab [FMC],2569291,CDM,250,RC,,,OUTPATIENT,1,EA,42.93,25.758,,36.49,85,,29.192,Percent of total billed charges,85% of total billed charges,21.47,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.47,50,,43.232,percent of total billed charges,50% of total billed charges,13.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.31,38,,13.048,percent of total billed charges,38% of total billed charges,17.17,40,,0.96,percent of total billed charges,40% of total billed charges,13.72,36.49,
ezetimibe 10 mg Tab [FMC],2569291,CDM,250,RC,,,OUTPATIENT,1,EA,42.93,25.758,,36.49,85,,29.192,Percent of total billed charges,85% of total billed charges,21.47,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.47,50,,83.336,percent of total billed charges,50% of total billed charges,13.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,13.72,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.31,38,,13.048,percent of total billed charges,38% of total billed charges,17.17,40,,0.96,percent of total billed charges,40% of total billed charges,13.72,36.49,
ezetimibe 10 mg Tab [FMC],2569291,CDM,250,RC,,,OUTPATIENT,1,EA,36.71,22.026,,31.2,85,,24.96,Percent of total billed charges,85% of total billed charges,18.36,50,,988,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.36,50,,87.088,percent of total billed charges,50% of total billed charges,11.73,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,11.73,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.95,38,,11.16,percent of total billed charges,38% of total billed charges,14.68,40,,1.92,percent of total billed charges,40% of total billed charges,11.73,31.2,
zinc sulfate 220 mg Cap [FMC],2569341,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,388.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,87.088,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
zinc sulfate 220 mg Cap [FMC],2569341,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
zinc oxide Top 20% Oint [FMC],2569366,CDM,250,RC,,,OUTPATIENT,60,EA,16.44,9.864,,13.97,85,,11.176,Percent of total billed charges,85% of total billed charges,8.22,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.22,50,,1.6,percent of total billed charges,50% of total billed charges,5.25,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,5.25,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.25,38,,5,percent of total billed charges,38% of total billed charges,6.58,40,,1.92,percent of total billed charges,40% of total billed charges,5.25,13.97,
zinc oxide Top 20% Oint [FMC],2569366,CDM,250,RC,,,OUTPATIENT,60,EA,16.05,9.63,,13.64,85,,10.912,Percent of total billed charges,85% of total billed charges,8.03,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.03,50,,1.6,percent of total billed charges,50% of total billed charges,5.13,31.95,,83.632,percent of total billed charges,31.95% of total billed charges,5.13,31.95,,83.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.1,38,,4.88,percent of total billed charges,38% of total billed charges,6.42,40,,104.704,percent of total billed charges,40% of total billed charges,5.13,13.64,
zinc oxide Top 20% Oint [FMC],2569366,CDM,250,RC,,,OUTPATIENT,60,EA,16.05,9.63,,13.64,85,,10.912,Percent of total billed charges,85% of total billed charges,8.03,50,,848,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.03,50,,1.6,percent of total billed charges,50% of total billed charges,5.13,31.95,,25.584,percent of total billed charges,31.95% of total billed charges,5.13,31.95,,25.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.1,38,,4.88,percent of total billed charges,38% of total billed charges,6.42,40,,32.032,percent of total billed charges,40% of total billed charges,5.13,13.64,
azithromycin 100 mg/5 mL Oral Liq [FMC],2569374,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,15,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,75.032,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,32.59,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,32.59,96.36,
azithromycin 100 mg/5 mL Oral Liq [FMC],2569374,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,15,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,75.032,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,34.51,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,34.51,96.36,
azithromycin 100 mg/5 mL Oral Liq [FMC],2569374,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,15,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,553.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,75.032,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,36.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,35.82,96.36,
azithromycin 200 mg/5 mL Oral REC 22.5 mL [FMC],2569390,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,22.5,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,75.032,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,36.83,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,35.82,96.36,
azithromycin 200 mg/5 mL Oral REC 22.5 mL [FMC],2569390,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,22.5,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,11.256,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,10.12,percent of total billed charges,35.15% of total billed charges,37.06,31.95,,42.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,35.82,96.36,
azithromycin 200 mg/5 mL Oral REC 30 mL [FMC],2569408,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,30,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,48,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,17.624,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,10.12,percent of total billed charges,35.15% of total billed charges,37.06,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,35.82,96.36,
azithromycin 200 mg/5 mL Oral REC 30 mL [FMC],2569408,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,30,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,48,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,22.648,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,10.12,percent of total billed charges,35.15% of total billed charges,37.06,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,35.82,96.36,
azithromycin 200 mg/5 mL Oral REC 30 mL [FMC],2569408,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,30,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,17.472,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,107.6,percent of total billed charges,35.15% of total billed charges,37.06,31.95,,43.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,97.808,percent of total billed charges,31.95% of total billed charges,35.82,96.36,
azithromycin 200 mg/5 mL Oral REC 30 mL [FMC],2569408,CDM,250,RC,Q0144,HCPCS,OUTPATIENT,30,ML,113.36,68.016,,96.36,85,,77.088,Percent of total billed charges,85% of total billed charges,35.82,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.82,136.6,,15.632,fee schedule,136.60% of BCBS custom fee schedule,39.85,35.15,,3.736,percent of total billed charges,35.15% of total billed charges,37.46,31.95,,3.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.08,38,,34.464,percent of total billed charges,38% of total billed charges,36.22,31.95,,4.68,percent of total billed charges,31.95% of total billed charges,35.82,96.36,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,8.67,5.202,,7.37,85,,5.896,Percent of total billed charges,85% of total billed charges,4.34,50,,53.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.34,50,,1.24,percent of total billed charges,50% of total billed charges,2.77,31.95,,3.768,percent of total billed charges,31.95% of total billed charges,2.77,31.95,,3.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.29,38,,2.632,percent of total billed charges,38% of total billed charges,3.47,40,,4.72,percent of total billed charges,40% of total billed charges,2.77,7.37,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,13.68,8.208,,11.63,85,,9.304,Percent of total billed charges,85% of total billed charges,6.84,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.84,50,,1.2,percent of total billed charges,50% of total billed charges,4.37,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4.37,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.2,38,,4.16,percent of total billed charges,38% of total billed charges,5.47,40,,3.84,percent of total billed charges,40% of total billed charges,4.37,11.63,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,13.7,8.22,,11.65,85,,9.32,Percent of total billed charges,85% of total billed charges,6.85,50,,54,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.85,50,,1.2,percent of total billed charges,50% of total billed charges,4.38,31.95,,4.48,percent of total billed charges,31.95% of total billed charges,4.38,31.95,,4.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.21,38,,4.168,percent of total billed charges,38% of total billed charges,5.48,40,,5.616,percent of total billed charges,40% of total billed charges,4.38,11.65,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,4.82,2.892,,4.1,85,,3.28,Percent of total billed charges,85% of total billed charges,2.41,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.41,50,,1.44,percent of total billed charges,50% of total billed charges,1.54,31.95,,3.856,percent of total billed charges,31.95% of total billed charges,1.54,31.95,,3.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.83,38,,1.464,percent of total billed charges,38% of total billed charges,1.93,40,,4.832,percent of total billed charges,40% of total billed charges,1.54,4.1,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,8.17,4.902,,6.94,85,,5.552,Percent of total billed charges,85% of total billed charges,4.09,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.09,50,,20.608,percent of total billed charges,50% of total billed charges,2.61,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,2.61,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.1,38,,2.48,percent of total billed charges,38% of total billed charges,3.27,40,,4.8,percent of total billed charges,40% of total billed charges,2.61,6.94,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,25.3,15.18,,21.51,85,,17.208,Percent of total billed charges,85% of total billed charges,12.65,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.65,50,,19.472,percent of total billed charges,50% of total billed charges,8.08,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,8.08,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.61,38,,7.688,percent of total billed charges,38% of total billed charges,10.12,40,,4.808,percent of total billed charges,40% of total billed charges,8.08,21.51,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,4.82,2.892,,4.1,85,,3.28,Percent of total billed charges,85% of total billed charges,2.41,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.41,50,,3.216,percent of total billed charges,50% of total billed charges,1.54,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,1.54,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.83,38,,1.464,percent of total billed charges,38% of total billed charges,1.93,40,,2.224,percent of total billed charges,40% of total billed charges,1.54,4.1,
azithromycin 250 mg Tab [FMC],2569416,CDM,250,RC,,,OUTPATIENT,1,EA,4.82,2.892,,4.1,85,,3.28,Percent of total billed charges,85% of total billed charges,2.41,50,,312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.41,50,,1.2,percent of total billed charges,50% of total billed charges,1.54,31.95,,1.624,percent of total billed charges,31.95% of total billed charges,1.54,31.95,,1.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.83,38,,1.464,percent of total billed charges,38% of total billed charges,1.93,40,,2.032,percent of total billed charges,40% of total billed charges,1.54,4.1,
azithromycin 500 mg IV Inj [FMC],2569424,CDM,250,RC,J0456,HCPCS,OUTPATIENT,1,EA,28.98,17.388,,24.63,85,,19.704,Percent of total billed charges,85% of total billed charges,2.69,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.69,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,10.19,35.15,,1.744,percent of total billed charges,35.15% of total billed charges,37.46,31.95,,1.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.01,38,,8.808,percent of total billed charges,38% of total billed charges,9.26,31.95,,2.184,percent of total billed charges,31.95% of total billed charges,2.69,37.46,
azithromycin 500 mg IV Inj [FMC],2569424,CDM,250,RC,J0456,HCPCS,OUTPATIENT,1,EA,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,2.69,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.69,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,1.776,percent of total billed charges,35.15% of total billed charges,37.46,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,2.224,percent of total billed charges,31.95% of total billed charges,2.69,37.46,
azithromycin 500 mg IV Inj [FMC],2569424,CDM,250,RC,J0456,HCPCS,OUTPATIENT,1,EA,19.5,11.7,,16.58,85,,13.264,Percent of total billed charges,85% of total billed charges,2.69,136.6,,1.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.69,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,6.85,35.15,,22.464,percent of total billed charges,35.15% of total billed charges,38.2,31.95,,22.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.41,38,,5.928,percent of total billed charges,38% of total billed charges,6.23,31.95,,28.128,percent of total billed charges,31.95% of total billed charges,2.69,38.2,
azithromycin 500 mg IV Inj [FMC],2569424,CDM,250,RC,J0456,HCPCS,OUTPATIENT,1,EA,28.99,17.394,,24.64,85,,19.712,Percent of total billed charges,85% of total billed charges,2.69,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.69,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,10.19,35.15,,7.648,percent of total billed charges,35.15% of total billed charges,38.2,31.95,,7.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,8.816,percent of total billed charges,38% of total billed charges,9.26,31.95,,9.576,percent of total billed charges,31.95% of total billed charges,2.69,38.2,
azithromycin 500 mg IV Inj [FMC],2569424,CDM,250,RC,J0456,HCPCS,OUTPATIENT,1,EA,56.23,33.738,,47.8,85,,38.24,Percent of total billed charges,85% of total billed charges,2.69,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.69,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,19.76,35.15,,11.624,percent of total billed charges,35.15% of total billed charges,38.2,31.95,,11.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.37,38,,17.096,percent of total billed charges,38% of total billed charges,17.97,31.95,,14.552,percent of total billed charges,31.95% of total billed charges,2.69,47.8,
azithromycin 500 mg IV Inj [FMC],2569424,CDM,250,RC,J0456,HCPCS,OUTPATIENT,1,EA,39.03,23.418,,33.18,85,,26.544,Percent of total billed charges,85% of total billed charges,2.69,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.69,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,13.72,35.15,,8.936,percent of total billed charges,35.15% of total billed charges,38.2,31.95,,8.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.83,38,,11.864,percent of total billed charges,38% of total billed charges,12.47,31.95,,11.192,percent of total billed charges,31.95% of total billed charges,2.69,38.2,
simvastatin 20 mg Tab UD [FMC],2569440,CDM,250,RC,,,OUTPATIENT,1,EA,15.99,9.594,,13.59,85,,10.872,Percent of total billed charges,85% of total billed charges,8,50,,37.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,1.6,percent of total billed charges,50% of total billed charges,5.11,31.95,,12.256,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,12.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,6.4,40,,15.344,percent of total billed charges,40% of total billed charges,5.11,13.59,
simvastatin 20 mg Tab UD [FMC],2569440,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,15.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,15.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,19.952,percent of total billed charges,40% of total billed charges,0.96,2.55,
simvastatin 20 mg Tab UD [FMC],2569440,CDM,250,RC,,,OUTPATIENT,1,EA,14.31,8.586,,12.16,85,,9.728,Percent of total billed charges,85% of total billed charges,7.16,50,,49.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.16,50,,164.712,percent of total billed charges,50% of total billed charges,4.57,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,4.57,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.44,38,,4.352,percent of total billed charges,38% of total billed charges,5.72,40,,1.744,percent of total billed charges,40% of total billed charges,4.57,12.16,
simvastatin 20 mg Tab UD [FMC],2569440,CDM,250,RC,,,OUTPATIENT,1,EA,15.99,9.594,,13.59,85,,10.872,Percent of total billed charges,85% of total billed charges,8,50,,0.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,143.224,percent of total billed charges,50% of total billed charges,5.11,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,6.4,40,,1.744,percent of total billed charges,40% of total billed charges,5.11,13.59,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,89.128,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,8.32,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.528,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.528,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,10.36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,13.76,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.136,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.136,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.424,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,10.896,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1.552,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1.552,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.944,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,57.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,16.864,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,16.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,21.112,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,16.864,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,16.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,21.112,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,17.168,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,16.864,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,16.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,21.112,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,38,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,390,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,16.864,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,16.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,21.112,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,374.4,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,16.864,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,16.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,21.112,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
ondansetron 2 mg/mL Inj Sol [FMC],2569465,CDM,250,RC,J2405,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.14,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,350.608,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,16.864,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,16.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,21.112,Fee Schedule,31.95% of LA custom fee schedule,0.14,10.2,
sertraline 50 mg Tab [FMC],2569515,CDM,250,RC,,,OUTPATIENT,1,EA,21.54,12.924,,18.31,85,,14.648,Percent of total billed charges,85% of total billed charges,10.77,50,,26.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.77,50,,351.008,percent of total billed charges,50% of total billed charges,6.88,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.88,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.19,38,,6.552,percent of total billed charges,38% of total billed charges,8.62,40,,0.96,percent of total billed charges,40% of total billed charges,6.88,18.31,
sertraline 50 mg Tab [FMC],2569515,CDM,250,RC,,,OUTPATIENT,1,EA,8.81,5.286,,7.49,85,,5.992,Percent of total billed charges,85% of total billed charges,4.41,50,,5.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.41,50,,351.008,percent of total billed charges,50% of total billed charges,2.81,31.95,,35.992,percent of total billed charges,31.95% of total billed charges,2.81,31.95,,43.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.35,38,,2.68,percent of total billed charges,38% of total billed charges,3.52,40,,32.712,percent of total billed charges,40% of total billed charges,2.81,7.49,
sertraline 50 mg Tab [FMC],2569515,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,574.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,729.576,percent of total billed charges,50% of total billed charges,0.96,31.95,,5.608,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,5.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.024,percent of total billed charges,40% of total billed charges,0.96,2.55,
sertraline 50 mg Tab [FMC],2569515,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,144.968,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.688,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,8.376,percent of total billed charges,40% of total billed charges,0.96,2.55,
sertraline 50 mg Tab,2569515,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.336,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.968,percent of total billed charges,40% of total billed charges,0.96,2.55,
zonisamide 100 mg Cap [FMC],2569531,CDM,250,RC,,,OUTPATIENT,1,EA,6.42,3.852,,5.46,85,,4.368,Percent of total billed charges,85% of total billed charges,3.21,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.21,50,,194.04,percent of total billed charges,50% of total billed charges,2.05,31.95,,13.976,percent of total billed charges,31.95% of total billed charges,2.05,31.95,,13.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.44,38,,1.952,percent of total billed charges,38% of total billed charges,2.57,40,,17.496,percent of total billed charges,40% of total billed charges,2.05,5.46,
zonisamide 100 mg Cap [FMC],2569531,CDM,250,RC,,,OUTPATIENT,1,EA,5.59,3.354,,4.75,85,,3.8,Percent of total billed charges,85% of total billed charges,2.8,50,,44.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.8,50,,237.904,percent of total billed charges,50% of total billed charges,1.79,31.95,,15.704,percent of total billed charges,31.95% of total billed charges,1.79,31.95,,15.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.12,38,,1.696,percent of total billed charges,38% of total billed charges,2.24,40,,19.656,percent of total billed charges,40% of total billed charges,1.79,4.75,
zonisamide 100 mg Cap [FMC],2569531,CDM,250,RC,,,OUTPATIENT,1,EA,7.13,4.278,,6.06,85,,4.848,Percent of total billed charges,85% of total billed charges,3.57,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.57,50,,238.776,percent of total billed charges,50% of total billed charges,2.28,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,2.28,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.71,38,,2.168,percent of total billed charges,38% of total billed charges,2.85,40,,3.896,percent of total billed charges,40% of total billed charges,2.28,6.06,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,70.7,42.42,,60.1,85,,48.08,Percent of total billed charges,85% of total billed charges,1.34,136.6,,35.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,10.888,fee schedule,136.60% of BCBS custom fee schedule,24.85,35.15,,3.112,percent of total billed charges,35.15% of total billed charges,38.2,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.87,38,,21.496,percent of total billed charges,38% of total billed charges,22.59,31.95,,3.904,percent of total billed charges,31.95% of total billed charges,1.34,60.1,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,54.09,32.454,,45.98,85,,36.784,Percent of total billed charges,85% of total billed charges,1.34,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,238.76,fee schedule,136.60% of BCBS custom fee schedule,19.01,35.15,,3.112,percent of total billed charges,35.15% of total billed charges,38.29,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.55,38,,16.44,percent of total billed charges,38% of total billed charges,17.28,31.95,,3.904,percent of total billed charges,31.95% of total billed charges,1.34,45.98,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,77.51,46.506,,65.88,85,,52.704,Percent of total billed charges,85% of total billed charges,1.34,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,9.808,fee schedule,136.60% of BCBS custom fee schedule,27.24,35.15,,8.912,percent of total billed charges,35.15% of total billed charges,39.62,31.95,,8.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.45,38,,23.56,percent of total billed charges,38% of total billed charges,24.76,31.95,,11.152,percent of total billed charges,31.95% of total billed charges,1.34,65.88,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,47.25,28.35,,40.16,85,,32.128,Percent of total billed charges,85% of total billed charges,1.34,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,265.2,fee schedule,136.60% of BCBS custom fee schedule,16.61,35.15,,8.912,percent of total billed charges,35.15% of total billed charges,39.94,31.95,,8.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.96,38,,14.368,percent of total billed charges,38% of total billed charges,15.1,31.95,,11.152,percent of total billed charges,31.95% of total billed charges,1.34,40.16,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,60.01,36.006,,51.01,85,,40.808,Percent of total billed charges,85% of total billed charges,1.34,136.6,,12.352,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,158.576,fee schedule,136.60% of BCBS custom fee schedule,21.09,35.15,,11.208,percent of total billed charges,35.15% of total billed charges,39.94,31.95,,11.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,19.17,31.95,,14.032,percent of total billed charges,31.95% of total billed charges,1.34,51.01,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,70.7,42.42,,60.1,85,,48.08,Percent of total billed charges,85% of total billed charges,1.34,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,158.576,fee schedule,136.60% of BCBS custom fee schedule,24.85,35.15,,6.168,percent of total billed charges,35.15% of total billed charges,4.15,31.95,,6.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.87,38,,21.496,percent of total billed charges,38% of total billed charges,22.59,31.95,,7.72,percent of total billed charges,31.95% of total billed charges,1.34,60.1,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,42.9,25.74,,36.47,85,,29.176,Percent of total billed charges,85% of total billed charges,1.34,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,90.792,fee schedule,136.60% of BCBS custom fee schedule,15.08,35.15,,5.552,percent of total billed charges,35.15% of total billed charges,41.54,31.95,,5.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.3,38,,13.04,percent of total billed charges,38% of total billed charges,13.71,31.95,,6.944,percent of total billed charges,31.95% of total billed charges,1.34,41.54,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,36.86,22.116,,31.33,85,,25.064,Percent of total billed charges,85% of total billed charges,1.34,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,76.128,fee schedule,136.60% of BCBS custom fee schedule,12.96,35.15,,4.088,percent of total billed charges,35.15% of total billed charges,41.54,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.01,38,,11.208,percent of total billed charges,38% of total billed charges,11.78,31.95,,5.12,percent of total billed charges,31.95% of total billed charges,1.34,41.54,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,54.09,32.454,,45.98,85,,36.784,Percent of total billed charges,85% of total billed charges,1.34,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,53.952,fee schedule,136.60% of BCBS custom fee schedule,19.01,35.15,,3.656,percent of total billed charges,35.15% of total billed charges,41.54,31.95,,3.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.55,38,,16.44,percent of total billed charges,38% of total billed charges,17.28,31.95,,4.576,percent of total billed charges,31.95% of total billed charges,1.34,45.98,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,54.09,32.454,,45.98,85,,36.784,Percent of total billed charges,85% of total billed charges,1.34,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,53.952,fee schedule,136.60% of BCBS custom fee schedule,19.01,35.15,,4.088,percent of total billed charges,35.15% of total billed charges,42.17,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.55,38,,16.44,percent of total billed charges,38% of total billed charges,17.28,31.95,,5.12,percent of total billed charges,31.95% of total billed charges,1.34,45.98,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,22.23,13.338,,18.9,85,,15.12,Percent of total billed charges,85% of total billed charges,1.34,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,58.792,fee schedule,136.60% of BCBS custom fee schedule,7.81,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,42.17,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.45,38,,6.76,percent of total billed charges,38% of total billed charges,7.1,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.34,42.17,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,20.09,12.054,,17.08,85,,13.664,Percent of total billed charges,85% of total billed charges,1.34,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,32.48,fee schedule,136.60% of BCBS custom fee schedule,7.06,35.15,,1.416,percent of total billed charges,35.15% of total billed charges,42.84,31.95,,1.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.63,38,,6.104,percent of total billed charges,38% of total billed charges,6.42,31.95,,1.776,percent of total billed charges,31.95% of total billed charges,1.34,42.84,
piperacillin-tazobactam 3 g-0.375 g IV Inj [FMC],2569564,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,55.82,33.492,,47.45,85,,37.96,Percent of total billed charges,85% of total billed charges,1.34,136.6,,5.72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,18.72,fee schedule,136.60% of BCBS custom fee schedule,19.62,35.15,,1.392,percent of total billed charges,35.15% of total billed charges,44.73,31.95,,1.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.21,38,,16.968,percent of total billed charges,38% of total billed charges,17.83,31.95,,1.744,percent of total billed charges,31.95% of total billed charges,1.34,47.45,
OLANZapine 5 mg Tab [FMC],2569614,CDM,250,RC,,,OUTPATIENT,1,EA,42.95,25.77,,36.51,85,,29.208,Percent of total billed charges,85% of total billed charges,21.48,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.48,50,,32.76,percent of total billed charges,50% of total billed charges,13.72,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,13.72,31.95,,1.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.32,38,,13.056,percent of total billed charges,38% of total billed charges,17.18,40,,1.752,percent of total billed charges,40% of total billed charges,13.72,36.51,
cetirizine 1mg/mL Liq UD oral syringe 5 mL [FMC],2569648,CDM,250,RC,,,OUTPATIENT,5,ML,4.94,2.964,,4.2,85,,3.36,Percent of total billed charges,85% of total billed charges,2.47,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.47,50,,11.312,percent of total billed charges,50% of total billed charges,1.58,31.95,,2.76,percent of total billed charges,31.95% of total billed charges,1.58,31.95,,2.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.88,38,,1.504,percent of total billed charges,38% of total billed charges,1.98,40,,3.456,percent of total billed charges,40% of total billed charges,1.58,4.2,
cetirizine 1mg/mL Liq UD oral syringe 5 mL [FMC],2569648,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.944,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
cetirizine 1mg/mL Liq UD oral syringe 5 mL [FMC],2569648,CDM,250,RC,,,OUTPATIENT,5,ML,4.94,2.964,,4.2,85,,3.36,Percent of total billed charges,85% of total billed charges,2.47,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.47,50,,1.6,percent of total billed charges,50% of total billed charges,1.58,31.95,,2.896,percent of total billed charges,31.95% of total billed charges,1.58,31.95,,2.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.88,38,,1.504,percent of total billed charges,38% of total billed charges,1.98,40,,3.624,percent of total billed charges,40% of total billed charges,1.58,4.2,
cetirizine 1mg/mL Liq UD oral syringe 5 mL [FMC],2569648,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.984,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetylcysteine 10% Inh Sol 4 mL [FMC],2569721,CDM,250,RC,J0132,HCPCS,OUTPATIENT,4,ML,43.68,26.208,,37.13,85,,29.704,Percent of total billed charges,85% of total billed charges,0.98,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,15.35,35.15,,3.784,percent of total billed charges,35.15% of total billed charges,44.73,31.95,,3.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.6,38,,13.28,percent of total billed charges,38% of total billed charges,13.96,31.95,,4.744,percent of total billed charges,31.95% of total billed charges,0.98,44.73,
acetylcysteine 10% Inh Sol 4 mL [FMC],2569721,CDM,250,RC,J0132,HCPCS,OUTPATIENT,4,ML,35.96,21.576,,30.57,85,,24.456,Percent of total billed charges,85% of total billed charges,0.98,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,12.64,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,44.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.66,38,,10.928,percent of total billed charges,38% of total billed charges,11.49,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,0.98,44.73,
prochlorperazine 5 mg/mL Inj Sol [FMC],2569739,CDM,250,RC,J0780,HCPCS,OUTPATIENT,2,ML,35.1,21.06,,29.84,85,,23.872,Percent of total billed charges,85% of total billed charges,4.29,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.29,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,12.34,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,11.21,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.34,38,,10.672,percent of total billed charges,38% of total billed charges,11.21,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,4.29,29.84,
prochlorperazine 5 mg/mL Inj Sol [FMC],2569739,CDM,250,RC,J0780,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,4.29,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.29,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,5.984,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,5.984,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,7.488,Fee Schedule,31.95% of LA custom fee schedule,3.83,10.2,
prochlorperazine 5 mg/mL Inj Sol [FMC],2569739,CDM,250,RC,J0780,HCPCS,OUTPATIENT,2,ML,70.2,42.12,,59.67,85,,47.736,Percent of total billed charges,85% of total billed charges,4.29,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.29,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,24.68,35.15,,6.832,fee schedule,35.15% of LA custom fee schedule,22.43,31.95,,6.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,26.68,38,,21.344,percent of total billed charges,38% of total billed charges,22.43,31.95,,8.552,Fee Schedule,31.95% of LA custom fee schedule,4.29,59.67,
prochlorperazine 5 mg/mL Inj Sol [FMC],2569739,CDM,250,RC,J0780,HCPCS,OUTPATIENT,2,ML,72.15,43.29,,61.33,85,,49.064,Percent of total billed charges,85% of total billed charges,4.29,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.29,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,25.36,35.15,,4.08,fee schedule,35.15% of LA custom fee schedule,23.05,31.95,,4.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.42,38,,21.936,percent of total billed charges,38% of total billed charges,23.05,31.95,,5.104,Fee Schedule,31.95% of LA custom fee schedule,4.29,61.33,
prochlorperazine 5 mg/mL Inj Sol [FMC],2569739,CDM,250,RC,J0780,HCPCS,OUTPATIENT,2,ML,20.67,12.402,,17.57,85,,14.056,Percent of total billed charges,85% of total billed charges,4.29,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.29,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,7.27,35.15,,5.912,fee schedule,35.15% of LA custom fee schedule,6.6,31.95,,5.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.85,38,,6.28,percent of total billed charges,38% of total billed charges,6.6,31.95,,7.4,Fee Schedule,31.95% of LA custom fee schedule,4.29,17.57,
prochlorperazine 5 mg/mL Inj Sol [FMC],2569739,CDM,250,RC,J0780,HCPCS,OUTPATIENT,2,ML,24.77,14.862,,21.05,85,,16.84,Percent of total billed charges,85% of total billed charges,4.29,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.29,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,8.71,35.15,,1.392,fee schedule,35.15% of LA custom fee schedule,7.91,31.95,,1.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.41,38,,7.528,percent of total billed charges,38% of total billed charges,7.91,31.95,,1.744,Fee Schedule,31.95% of LA custom fee schedule,4.29,21.05,
prochlorperazine 5 mg/mL Inj Sol [FMC],2569739,CDM,250,RC,J0780,HCPCS,OUTPATIENT,2,ML,17.9,10.74,,15.22,85,,12.176,Percent of total billed charges,85% of total billed charges,4.29,136.6,,80.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.29,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,6.29,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,5.72,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.8,38,,5.44,percent of total billed charges,38% of total billed charges,5.72,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,4.29,15.22,
phenytoin 100 mg/4 mL Oral Susp [FMC],2569804,CDM,250,RC,,,OUTPATIENT,4,ML,5.07,3.042,,4.31,85,,3.448,Percent of total billed charges,85% of total billed charges,2.54,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.54,50,,1.6,percent of total billed charges,50% of total billed charges,1.62,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.62,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.93,38,,1.544,percent of total billed charges,38% of total billed charges,2.03,40,,0.96,percent of total billed charges,40% of total billed charges,1.62,4.31,
phenytoin 100 mg/4 mL Oral Susp [FMC],2569804,CDM,250,RC,,,OUTPATIENT,4,ML,28.08,16.848,,23.87,85,,19.096,Percent of total billed charges,85% of total billed charges,14.04,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.04,50,,2.4,percent of total billed charges,50% of total billed charges,8.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,8.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.67,38,,8.536,percent of total billed charges,38% of total billed charges,11.23,40,,0.96,percent of total billed charges,40% of total billed charges,8.97,23.87,
phenytoin 100 mg/4 mL Oral Susp [FMC],2569804,CDM,250,RC,,,OUTPATIENT,4,ML,19.1,11.46,,16.24,85,,12.992,Percent of total billed charges,85% of total billed charges,9.55,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.55,50,,1.2,percent of total billed charges,50% of total billed charges,6.1,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,6.1,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.26,38,,5.808,percent of total billed charges,38% of total billed charges,7.64,40,,1.36,percent of total billed charges,40% of total billed charges,6.1,16.24,
diltiazem 5 mg/mL IV 25mL Sol [FMC],2569887,CDM,250,RC,,,OUTPATIENT,25,ML,35.49,21.294,,30.17,85,,24.136,Percent of total billed charges,85% of total billed charges,17.75,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.75,50,,1.2,percent of total billed charges,50% of total billed charges,11.34,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.34,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.49,38,,10.792,percent of total billed charges,38% of total billed charges,14.2,40,,0.96,percent of total billed charges,40% of total billed charges,11.34,30.17,
diltiazem 5 mg/mL IV 25ml Sol [FMC],2569887,CDM,250,RC,,,OUTPATIENT,25,ML,44.36,26.616,,37.71,85,,30.168,Percent of total billed charges,85% of total billed charges,22.18,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.18,50,,180.056,percent of total billed charges,50% of total billed charges,14.17,31.95,,6.088,percent of total billed charges,31.95% of total billed charges,14.17,31.95,,6.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.86,38,,13.488,percent of total billed charges,38% of total billed charges,17.74,40,,7.616,percent of total billed charges,40% of total billed charges,14.17,37.71,
diltiazem 5 mg/mL IV 25mL Sol [FMC],2569887,CDM,250,RC,,,OUTPATIENT,25,ML,38.03,22.818,,32.33,85,,25.864,Percent of total billed charges,85% of total billed charges,19.02,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.02,50,,1.2,percent of total billed charges,50% of total billed charges,12.15,31.95,,6.112,percent of total billed charges,31.95% of total billed charges,12.15,31.95,,6.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.45,38,,11.56,percent of total billed charges,38% of total billed charges,15.21,40,,7.656,percent of total billed charges,40% of total billed charges,12.15,32.33,
diltiazem 5 mg/mL IV 25mL Sol [FMC],2569887,CDM,250,RC,,,OUTPATIENT,25,ML,22.62,13.572,,19.23,85,,15.384,Percent of total billed charges,85% of total billed charges,11.31,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.31,50,,45.24,percent of total billed charges,50% of total billed charges,7.23,31.95,,4.4,percent of total billed charges,31.95% of total billed charges,7.23,31.95,,4.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.6,38,,6.88,percent of total billed charges,38% of total billed charges,9.05,40,,5.504,percent of total billed charges,40% of total billed charges,7.23,19.23,
fosinopril 10 mg Tab [FMC],2569903,CDM,250,RC,,,OUTPATIENT,1,EA,3.87,2.322,,3.29,85,,2.632,Percent of total billed charges,85% of total billed charges,1.94,50,,42.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.94,50,,45.24,percent of total billed charges,50% of total billed charges,1.24,31.95,,36.296,percent of total billed charges,31.95% of total billed charges,1.24,31.95,,43.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.47,38,,1.176,percent of total billed charges,38% of total billed charges,1.55,40,,32.992,percent of total billed charges,40% of total billed charges,1.24,3.29,
primidone 50 mg Tab [FMC],2569903,CDM,250,RC,,,OUTPATIENT,1,EA,3.87,2.322,,3.29,85,,2.632,Percent of total billed charges,85% of total billed charges,1.94,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.94,50,,40.728,percent of total billed charges,50% of total billed charges,1.24,31.95,,54.04,percent of total billed charges,31.95% of total billed charges,1.24,31.95,,54.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.47,38,,1.176,percent of total billed charges,38% of total billed charges,1.55,40,,67.648,percent of total billed charges,40% of total billed charges,1.24,3.29,
primidone 50 mg Tab [FMC],2569903,CDM,250,RC,,,OUTPATIENT,1,EA,6.57,3.942,,5.58,85,,4.464,Percent of total billed charges,85% of total billed charges,3.29,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.29,50,,40.696,percent of total billed charges,50% of total billed charges,2.1,31.95,,2.888,percent of total billed charges,31.95% of total billed charges,2.1,31.95,,2.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.5,38,,2,percent of total billed charges,38% of total billed charges,2.63,40,,3.616,percent of total billed charges,40% of total billed charges,2.1,5.58,
fosinopril 10 mg Tab [FMC],2569903,CDM,250,RC,,,OUTPATIENT,1,EA,3.84,2.304,,3.26,85,,2.608,Percent of total billed charges,85% of total billed charges,1.92,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.92,50,,40.696,percent of total billed charges,50% of total billed charges,1.23,31.95,,5.512,percent of total billed charges,31.95% of total billed charges,1.23,31.95,,5.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.46,38,,1.168,percent of total billed charges,38% of total billed charges,1.54,40,,6.896,percent of total billed charges,40% of total billed charges,1.23,3.26,
dapsone 100 mg Tab [FMC],2569937,CDM,250,RC,,,OUTPATIENT,1,EA,10.92,6.552,,9.28,85,,7.424,Percent of total billed charges,85% of total billed charges,5.46,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.46,50,,40.696,percent of total billed charges,50% of total billed charges,3.49,31.95,,2.792,percent of total billed charges,31.95% of total billed charges,3.49,31.95,,2.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.15,38,,3.32,percent of total billed charges,38% of total billed charges,4.37,40,,3.496,percent of total billed charges,40% of total billed charges,3.49,9.28,
dapsone 100 mg Tab [FMC],2569937,CDM,250,RC,,,OUTPATIENT,1,EA,9.83,5.898,,8.36,85,,6.688,Percent of total billed charges,85% of total billed charges,4.92,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.92,50,,32.824,percent of total billed charges,50% of total billed charges,3.14,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,3.14,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.74,38,,2.992,percent of total billed charges,38% of total billed charges,3.93,40,,4.928,percent of total billed charges,40% of total billed charges,3.14,8.36,
insulin regular human recombinant 100 units/mL Sol 10 mL [FMC],2570000,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,53.7,32.22,,45.65,85,,36.52,Percent of total billed charges,85% of total billed charges,0.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,3.168,fee schedule,136.60% of BCBS custom fee schedule,18.88,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,17.16,31.95,,43.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.41,38,,16.328,percent of total billed charges,38% of total billed charges,17.16,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,0.76,45.65,
insulin regular human recombinant 100 units/mL Sol 10 mL [FM,2570000,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,57.99,34.794,,49.29,85,,39.432,Percent of total billed charges,85% of total billed charges,0.76,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,23.864,fee schedule,136.60% of BCBS custom fee schedule,20.38,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,18.53,31.95,,43.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,17.632,percent of total billed charges,38% of total billed charges,18.53,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,0.76,49.29,
insulin regular human recombinant 100 units/mL Sol 10 mL [FMC],2570000,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,57.99,34.794,,49.29,85,,39.432,Percent of total billed charges,85% of total billed charges,0.76,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,24.096,fee schedule,136.60% of BCBS custom fee schedule,20.38,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,18.53,31.95,,44.32,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,17.632,percent of total billed charges,38% of total billed charges,18.53,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,0.76,49.29,
nystatin and triamcinolone acetonide oint [FMC],2570075,CDM,250,RC,,,OUTPATIENT,15,EA,168.81,101.286,,143.49,85,,114.792,Percent of total billed charges,85% of total billed charges,84.41,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84.41,50,,23.864,percent of total billed charges,50% of total billed charges,53.93,31.95,,65.8,percent of total billed charges,31.95% of total billed charges,53.93,31.95,,44.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.15,38,,51.32,percent of total billed charges,38% of total billed charges,67.52,40,,59.808,percent of total billed charges,40% of total billed charges,53.93,143.49,
nystatin and triamcinolone acetonide oint [FMC],2570075,CDM,250,RC,,,OUTPATIENT,15,EA,168.81,101.286,,143.49,85,,114.792,Percent of total billed charges,85% of total billed charges,84.41,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84.41,50,,3.536,percent of total billed charges,50% of total billed charges,53.93,31.95,,13.952,percent of total billed charges,31.95% of total billed charges,53.93,31.95,,13.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.15,38,,51.32,percent of total billed charges,38% of total billed charges,67.52,40,,17.464,percent of total billed charges,40% of total billed charges,53.93,143.49,
nystatin and triamcinolone acetonide oint [FMC],2570075,CDM,250,RC,,,OUTPATIENT,15,EA,63.38,38.028,,53.87,85,,43.096,Percent of total billed charges,85% of total billed charges,31.69,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.69,50,,3.424,percent of total billed charges,50% of total billed charges,20.25,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,20.25,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.08,38,,19.264,percent of total billed charges,38% of total billed charges,25.35,40,,11.52,percent of total billed charges,40% of total billed charges,20.25,53.87,
metolazone 5 mg Tab [FMC],2570133,CDM,250,RC,,,OUTPATIENT,1,EA,12.13,7.278,,10.31,85,,8.248,Percent of total billed charges,85% of total billed charges,6.07,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.07,50,,4.736,percent of total billed charges,50% of total billed charges,3.88,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,3.88,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.61,38,,3.688,percent of total billed charges,38% of total billed charges,4.85,40,,11.52,percent of total billed charges,40% of total billed charges,3.88,10.31,
metOLazone 5 mg TabmetOLazone 5 mg Tab,2570133,CDM,250,RC,,,OUTPATIENT,1,EA,7.66,4.596,,6.51,85,,5.208,Percent of total billed charges,85% of total billed charges,3.83,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.83,50,,4.232,percent of total billed charges,50% of total billed charges,2.45,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,2.45,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.91,38,,2.328,percent of total billed charges,38% of total billed charges,3.06,40,,11.136,percent of total billed charges,40% of total billed charges,2.45,6.51,
lidocaine topical 4% Kit [FMC],2570182,CDM,250,RC,,,OUTPATIENT,1,EA,97.5,58.5,,82.88,85,,66.304,Percent of total billed charges,85% of total billed charges,48.75,50,,4.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48.75,50,,28.08,percent of total billed charges,50% of total billed charges,31.15,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,31.15,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.05,38,,29.64,percent of total billed charges,38% of total billed charges,39,40,,11.136,percent of total billed charges,40% of total billed charges,31.15,82.88,
isoniazid 300 mg Tab [FMC],2570232,CDM,250,RC,,,OUTPATIENT,1,EA,4.19,2.514,,3.56,85,,2.848,Percent of total billed charges,85% of total billed charges,2.1,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.1,50,,6.608,percent of total billed charges,50% of total billed charges,1.34,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,1.34,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.59,38,,1.272,percent of total billed charges,38% of total billed charges,1.68,40,,11.136,percent of total billed charges,40% of total billed charges,1.34,3.56,
isoniazid 300 mg Tab [FMC],2570232,CDM,250,RC,,,OUTPATIENT,1,EA,3.78,2.268,,3.21,85,,2.568,Percent of total billed charges,85% of total billed charges,1.89,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.89,50,,1.2,percent of total billed charges,50% of total billed charges,1.21,31.95,,103.008,percent of total billed charges,31.95% of total billed charges,1.21,31.95,,103.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.44,38,,1.152,percent of total billed charges,38% of total billed charges,1.51,40,,128.96,percent of total billed charges,40% of total billed charges,1.21,3.21,
isoniazid 300 mg Tab [FMC],2570232,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.352,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
alfuzosin 10 mg ER [FMC],2570273,CDM,250,RC,,,OUTPATIENT,1,EA,13.71,8.226,,11.65,85,,9.32,Percent of total billed charges,85% of total billed charges,6.86,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.86,50,,1.2,percent of total billed charges,50% of total billed charges,4.38,31.95,,14.112,percent of total billed charges,31.95% of total billed charges,4.38,31.95,,14.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.21,38,,4.168,percent of total billed charges,38% of total billed charges,5.48,40,,17.664,percent of total billed charges,40% of total billed charges,4.38,11.65,
alfuzosin 10 mg ER [FMC],2570273,CDM,250,RC,,,OUTPATIENT,1,EA,13.71,8.226,,11.65,85,,9.32,Percent of total billed charges,85% of total billed charges,6.86,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.86,50,,1.2,percent of total billed charges,50% of total billed charges,4.38,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,4.38,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.21,38,,4.168,percent of total billed charges,38% of total billed charges,5.48,40,,11.52,percent of total billed charges,40% of total billed charges,4.38,11.65,
alfuzosin 10 mg ER [FMC],2570273,CDM,250,RC,,,OUTPATIENT,1,EA,13.69,8.214,,11.64,85,,9.312,Percent of total billed charges,85% of total billed charges,6.85,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.85,50,,3.552,percent of total billed charges,50% of total billed charges,4.37,31.95,,10.96,percent of total billed charges,31.95% of total billed charges,4.37,31.95,,10.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.2,38,,4.16,percent of total billed charges,38% of total billed charges,5.48,40,,13.72,percent of total billed charges,40% of total billed charges,4.37,11.64,
alfuzosin 10 mg ER [FMC],2570273,CDM,250,RC,,,OUTPATIENT,1,EA,13.69,8.214,,11.64,85,,9.312,Percent of total billed charges,85% of total billed charges,6.85,50,,24.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.85,50,,1.384,percent of total billed charges,50% of total billed charges,4.37,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,4.37,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.2,38,,4.16,percent of total billed charges,38% of total billed charges,5.48,40,,11.52,percent of total billed charges,40% of total billed charges,4.37,11.64,
DULoxetine 30 mg DR [FMC],2570331,CDM,250,RC,,,OUTPATIENT,1,EA,25.03,15.018,,21.28,85,,17.024,Percent of total billed charges,85% of total billed charges,12.52,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.52,50,,45.504,percent of total billed charges,50% of total billed charges,8,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,8,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.51,38,,7.608,percent of total billed charges,38% of total billed charges,10.01,40,,11.52,percent of total billed charges,40% of total billed charges,8,21.28,
DULoxetine 30 mg DR [FMC],2570331,CDM,250,RC,,,OUTPATIENT,1,EA,19.26,11.556,,16.37,85,,13.096,Percent of total billed charges,85% of total billed charges,9.63,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.63,50,,48.104,percent of total billed charges,50% of total billed charges,6.15,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,6.15,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.32,38,,5.856,percent of total billed charges,38% of total billed charges,7.7,40,,5.68,percent of total billed charges,40% of total billed charges,6.15,16.37,
DULoxetine 30 mg DR [FMC],2570331,CDM,250,RC,,,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,13.408,percent of total billed charges,50% of total billed charges,3.83,31.95,,5.976,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,5.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,7.488,percent of total billed charges,40% of total billed charges,3.83,10.2,
DULoxetine 30 mg DR [FMC],2570331,CDM,250,RC,,,OUTPATIENT,1,EA,25.52,15.312,,21.69,85,,17.352,Percent of total billed charges,85% of total billed charges,12.76,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.76,50,,12.784,percent of total billed charges,50% of total billed charges,8.15,31.95,,6.216,percent of total billed charges,31.95% of total billed charges,8.15,31.95,,6.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.7,38,,7.76,percent of total billed charges,38% of total billed charges,10.21,40,,7.776,percent of total billed charges,40% of total billed charges,8.15,21.69,
DULoxetine 20 mg Cap [FMC],2570356,CDM,250,RC,,,OUTPATIENT,1,EA,26.54,15.924,,22.56,85,,18.048,Percent of total billed charges,85% of total billed charges,13.27,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.27,50,,86.664,percent of total billed charges,50% of total billed charges,8.48,31.95,,6.488,percent of total billed charges,31.95% of total billed charges,8.48,31.95,,6.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.09,38,,8.072,percent of total billed charges,38% of total billed charges,10.62,40,,8.128,percent of total billed charges,40% of total billed charges,8.48,22.56,
DULoxetine 20 mg Cap [FMC],2570356,CDM,250,RC,,,OUTPATIENT,1,EA,26.53,15.918,,22.55,85,,18.04,Percent of total billed charges,85% of total billed charges,13.27,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.27,50,,86.664,percent of total billed charges,50% of total billed charges,8.48,31.95,,171.352,percent of total billed charges,31.95% of total billed charges,8.48,31.95,,171.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.08,38,,8.064,percent of total billed charges,38% of total billed charges,10.61,40,,214.528,percent of total billed charges,40% of total billed charges,8.48,22.55,
DULoxetine 20 mg Cap [FMC],2570356,CDM,250,RC,,,OUTPATIENT,1,EA,6.26,3.756,,5.32,85,,4.256,Percent of total billed charges,85% of total billed charges,3.13,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.13,50,,67.08,percent of total billed charges,50% of total billed charges,2,31.95,,209.336,percent of total billed charges,31.95% of total billed charges,2,31.95,,209.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.38,38,,1.904,percent of total billed charges,38% of total billed charges,2.5,40,,262.08,percent of total billed charges,40% of total billed charges,2,5.32,
nadolol 20 mg Tab [FMC],2570422,CDM,250,RC,,,OUTPATIENT,1,EA,11.03,6.618,,9.38,85,,7.504,Percent of total billed charges,85% of total billed charges,5.52,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.52,50,,69.88,percent of total billed charges,50% of total billed charges,3.52,31.95,,5.632,percent of total billed charges,31.95% of total billed charges,3.52,31.95,,5.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.19,38,,3.352,percent of total billed charges,38% of total billed charges,4.41,40,,7.056,percent of total billed charges,40% of total billed charges,3.52,9.38,
nadolol 20 mg Tab [FMC],2570422,CDM,250,RC,,,OUTPATIENT,1,EA,12.02,7.212,,10.22,85,,8.176,Percent of total billed charges,85% of total billed charges,6.01,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.01,50,,14.4,percent of total billed charges,50% of total billed charges,3.84,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,3.84,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.57,38,,3.656,percent of total billed charges,38% of total billed charges,4.81,40,,0.992,percent of total billed charges,40% of total billed charges,3.84,10.22,
fenofibrate 145 mg Tab [FMC],2570448,CDM,250,RC,,,OUTPATIENT,1,EA,16.74,10.044,,14.23,85,,11.384,Percent of total billed charges,85% of total billed charges,8.37,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.37,50,,14.4,percent of total billed charges,50% of total billed charges,5.35,31.95,,5.072,percent of total billed charges,31.95% of total billed charges,5.35,31.95,,5.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.36,38,,5.088,percent of total billed charges,38% of total billed charges,6.7,40,,6.344,percent of total billed charges,40% of total billed charges,5.35,14.23,
fenofibrate 145 mg Tab [FMC],2570448,CDM,250,RC,,,OUTPATIENT,1,EA,5.76,3.456,,4.9,85,,3.92,Percent of total billed charges,85% of total billed charges,2.88,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.88,50,,2.4,percent of total billed charges,50% of total billed charges,1.84,31.95,,22.792,percent of total billed charges,31.95% of total billed charges,1.84,31.95,,22.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.19,38,,1.752,percent of total billed charges,38% of total billed charges,2.3,40,,28.536,percent of total billed charges,40% of total billed charges,1.84,4.9,
dextromethorp-guaiFEN 20 mg-200 mg/10 mL Oral Liq 10 mL [FMC],2570455,CDM,250,RC,,,OUTPATIENT,10,ML,11.7,7.02,,9.95,85,,7.96,Percent of total billed charges,85% of total billed charges,5.85,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.85,50,,3.264,percent of total billed charges,50% of total billed charges,3.74,31.95,,12.96,percent of total billed charges,31.95% of total billed charges,3.74,31.95,,12.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.45,38,,3.56,percent of total billed charges,38% of total billed charges,4.68,40,,16.224,percent of total billed charges,40% of total billed charges,3.74,9.95,
dextromethorp-guaiFEN 20 mg-200 mg/10 mL Oral Liq 10 mL [FMC],2570455,CDM,250,RC,,,OUTPATIENT,10,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,13.456,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,13.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,16.848,percent of total billed charges,40% of total billed charges,0.96,2.55,
dextromethorp-guaiFEN 20 mg-200 mg/10 mL Oral Liq 10 mL [FMC],2570455,CDM,250,RC,,,OUTPATIENT,10,ML,9.37,5.622,,7.96,85,,6.368,Percent of total billed charges,85% of total billed charges,4.69,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.69,50,,3.456,percent of total billed charges,50% of total billed charges,2.99,31.95,,14.032,percent of total billed charges,31.95% of total billed charges,2.99,31.95,,14.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.56,38,,2.848,percent of total billed charges,38% of total billed charges,3.75,40,,17.568,percent of total billed charges,40% of total billed charges,2.99,7.96,
ammonia vaporoles [FMC],2570562,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,31.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,73.504,percent of total billed charges,50% of total billed charges,1.92,31.95,,3.52,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,3.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,4.408,percent of total billed charges,40% of total billed charges,1.92,5.1,
ammonia vaporoles [FMC],2570562,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,23.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,68.704,percent of total billed charges,50% of total billed charges,1.92,31.95,,4.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,4.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,5.968,percent of total billed charges,40% of total billed charges,1.92,5.1,
glimepiride 1 mg Tab [FMC],2570646,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,18.264,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.52,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.408,percent of total billed charges,40% of total billed charges,0.96,2.55,
glimepiride 1 mg Tab [FMC],2570646,CDM,250,RC,,,OUTPATIENT,1,EA,3.27,1.962,,2.78,85,,2.224,Percent of total billed charges,85% of total billed charges,1.64,50,,19.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.64,50,,9.568,percent of total billed charges,50% of total billed charges,1.04,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.04,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.24,38,,0.992,percent of total billed charges,38% of total billed charges,1.31,40,,0.96,percent of total billed charges,40% of total billed charges,1.04,2.78,
buPROPion 150 mg/24 hours ER Tab [FMC],2570661,CDM,250,RC,,,OUTPATIENT,1,EA,16.95,10.17,,14.41,85,,11.528,Percent of total billed charges,85% of total billed charges,8.48,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.48,50,,16.216,percent of total billed charges,50% of total billed charges,5.42,31.95,,1.096,percent of total billed charges,31.95% of total billed charges,5.42,31.95,,1.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.44,38,,5.152,percent of total billed charges,38% of total billed charges,6.78,40,,1.376,percent of total billed charges,40% of total billed charges,5.42,14.41,
buPROPion 150 mg/24 hours ER,2570661,CDM,250,RC,,,OUTPATIENT,1,EA,16.97,10.182,,14.42,85,,11.536,Percent of total billed charges,85% of total billed charges,8.49,50,,9.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.49,50,,16.736,percent of total billed charges,50% of total billed charges,5.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.42,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.45,38,,5.16,percent of total billed charges,38% of total billed charges,6.79,40,,0.96,percent of total billed charges,40% of total billed charges,5.42,14.42,
buPROPion 150 mg/24 hours ER Tab [FMC],2570661,CDM,250,RC,,,OUTPATIENT,1,EA,15.51,9.306,,13.18,85,,10.544,Percent of total billed charges,85% of total billed charges,7.76,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.76,50,,16.736,percent of total billed charges,50% of total billed charges,4.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,4.96,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.89,38,,4.712,percent of total billed charges,38% of total billed charges,6.2,40,,1.104,percent of total billed charges,40% of total billed charges,4.96,13.18,
buPROPion 150 mg/24 hours ER,2570661,CDM,250,RC,,,OUTPATIENT,1,EA,25.23,15.138,,21.45,85,,17.16,Percent of total billed charges,85% of total billed charges,12.62,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.62,50,,19.864,percent of total billed charges,50% of total billed charges,8.06,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,8.06,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.59,38,,7.672,percent of total billed charges,38% of total billed charges,10.09,40,,1.28,percent of total billed charges,40% of total billed charges,8.06,21.45,
buPROPion 150 mg/24 hours ER Tab [FMC],2570661,CDM,250,RC,,,OUTPATIENT,1,EA,16.97,10.182,,14.42,85,,11.536,Percent of total billed charges,85% of total billed charges,8.49,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.49,50,,35.8,percent of total billed charges,50% of total billed charges,5.42,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,5.42,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.45,38,,5.16,percent of total billed charges,38% of total billed charges,6.79,40,,1.28,percent of total billed charges,40% of total billed charges,5.42,14.42,
buPROPion 150 mg/24 hours ER Tab [FMC],2570661,CDM,250,RC,,,OUTPATIENT,1,EA,15.14,9.084,,12.87,85,,10.296,Percent of total billed charges,85% of total billed charges,7.57,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.57,50,,15.264,percent of total billed charges,50% of total billed charges,4.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.84,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.75,38,,4.6,percent of total billed charges,38% of total billed charges,6.06,40,,0.96,percent of total billed charges,40% of total billed charges,4.84,12.87,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,17.04,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,349.728,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,364.304,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.176,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,44.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.8,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,17.04,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,388.584,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.032,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,44.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.664,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,13.96,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,0.896,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,0.896,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1.12,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,15.21,9.126,,12.93,85,,10.344,Percent of total billed charges,85% of total billed charges,0.71,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,13.96,fee schedule,136.60% of BCBS custom fee schedule,5.35,35.15,,9.432,fee schedule,35.15% of LA custom fee schedule,4.86,31.95,,9.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.78,38,,4.624,percent of total billed charges,38% of total billed charges,4.86,31.95,,11.808,Fee Schedule,31.95% of LA custom fee schedule,0.71,12.93,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,32.096,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,9.432,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,9.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,11.808,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,26.12,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,6.168,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,6.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,7.72,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 1 g Inj [FMC],2570711,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,149.33,89.598,,126.93,85,,101.544,Percent of total billed charges,85% of total billed charges,0.71,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,26.264,fee schedule,136.60% of BCBS custom fee schedule,52.49,35.15,,5.856,fee schedule,35.15% of LA custom fee schedule,47.71,31.95,,5.856,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,56.75,38,,45.4,percent of total billed charges,38% of total billed charges,47.71,31.95,,7.336,Fee Schedule,31.95% of LA custom fee schedule,0.71,126.93,
cefTRIAXone 500 mg Inj [FMC],2570729,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,87.36,52.416,,74.26,85,,59.408,Percent of total billed charges,85% of total billed charges,0.71,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,25.04,fee schedule,136.60% of BCBS custom fee schedule,30.71,35.15,,22.792,fee schedule,35.15% of LA custom fee schedule,27.91,31.95,,22.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.2,38,,26.56,percent of total billed charges,38% of total billed charges,27.91,31.95,,28.536,Fee Schedule,31.95% of LA custom fee schedule,0.71,74.26,
cefTRIAXone 500 mg Inj [FMC],2570729,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,26.264,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,13.456,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,13.456,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,16.848,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 500 mg Inj [FMC],2570729,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,76.9,46.14,,65.37,85,,52.296,Percent of total billed charges,85% of total billed charges,0.71,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,6.92,fee schedule,136.60% of BCBS custom fee schedule,27.03,35.15,,14.032,fee schedule,35.15% of LA custom fee schedule,24.57,31.95,,14.032,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.22,38,,23.376,percent of total billed charges,38% of total billed charges,24.57,31.95,,17.568,Fee Schedule,31.95% of LA custom fee schedule,0.71,65.37,
cefTRIAXone 500 mg Inj [FMC],2570729,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,9.648,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,10.984,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,10.984,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,13.752,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
cefTRIAXone 500 mg Inj [FMC],2570729,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,24.38,14.628,,20.72,85,,16.576,Percent of total billed charges,85% of total billed charges,0.71,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,5.616,fee schedule,136.60% of BCBS custom fee schedule,8.57,35.15,,17.328,fee schedule,35.15% of LA custom fee schedule,7.79,31.95,,17.328,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.26,38,,7.408,percent of total billed charges,38% of total billed charges,7.79,31.95,,21.688,Fee Schedule,31.95% of LA custom fee schedule,0.71,20.72,
cefTRIAXone 250 mg Inj [FMC],2570737,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,16.25,9.75,,13.81,85,,11.048,Percent of total billed charges,85% of total billed charges,0.71,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,5.71,35.15,,42.904,fee schedule,35.15% of LA custom fee schedule,5.19,31.95,,42.904,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.18,38,,4.944,percent of total billed charges,38% of total billed charges,5.19,31.95,,53.72,Fee Schedule,31.95% of LA custom fee schedule,0.71,13.81,
cefTRIAXone 250 mg Inj [FMC],2570737,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,48.2,28.92,,40.97,85,,32.776,Percent of total billed charges,85% of total billed charges,0.71,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,70.648,fee schedule,136.60% of BCBS custom fee schedule,16.94,35.15,,47.192,fee schedule,35.15% of LA custom fee schedule,15.4,31.95,,47.192,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.32,38,,14.656,percent of total billed charges,38% of total billed charges,15.4,31.95,,59.08,Fee Schedule,31.95% of LA custom fee schedule,0.71,40.97,
cefTRIAXone 250 mg Inj [FMC],2570737,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,54.392,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,30.072,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,30.072,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,37.648,Fee Schedule,31.95% of LA custom fee schedule,0.71,10.2,
simvastatin 5 mg Tab [FMC],2570752,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,45.504,percent of total billed charges,50% of total billed charges,0.96,31.95,,45.544,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,45.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,57.016,percent of total billed charges,40% of total billed charges,0.96,2.55,
simvastatin 5 mg Tab [FMC],2570752,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,18.016,percent of total billed charges,50% of total billed charges,0.96,31.95,,43.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,43.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,54.728,percent of total billed charges,40% of total billed charges,0.96,2.55,
simvastatin 5 mg Tab [FMC],2570752,CDM,250,RC,,,OUTPATIENT,1,EA,9.46,5.676,,8.04,85,,6.432,Percent of total billed charges,85% of total billed charges,4.73,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.73,50,,18.136,percent of total billed charges,50% of total billed charges,3.02,31.95,,13.584,percent of total billed charges,31.95% of total billed charges,3.02,31.95,,13.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.78,40,,17.008,percent of total billed charges,40% of total billed charges,3.02,8.04,
simvastatin 5 mg Tab [FMC],2570752,CDM,250,RC,,,OUTPATIENT,1,EA,9.14,5.484,,7.77,85,,6.216,Percent of total billed charges,85% of total billed charges,4.57,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.57,50,,3.248,percent of total billed charges,50% of total billed charges,2.92,31.95,,6.336,percent of total billed charges,31.95% of total billed charges,2.92,31.95,,6.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.47,38,,2.776,percent of total billed charges,38% of total billed charges,3.66,40,,7.928,percent of total billed charges,40% of total billed charges,2.92,7.77,
simvastatin 5 mg Tab [FMC],2570752,CDM,250,RC,,,OUTPATIENT,1,EA,6.82,4.092,,5.8,85,,4.64,Percent of total billed charges,85% of total billed charges,3.41,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.41,50,,5.136,percent of total billed charges,50% of total billed charges,2.18,31.95,,6.336,percent of total billed charges,31.95% of total billed charges,2.18,31.95,,6.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.59,38,,2.072,percent of total billed charges,38% of total billed charges,2.73,40,,7.928,percent of total billed charges,40% of total billed charges,2.18,5.8,
galantamine 4 mg Tab [FMC],2570778,CDM,250,RC,,,OUTPATIENT,1,EA,10.33,6.198,,8.78,85,,7.024,Percent of total billed charges,85% of total billed charges,5.17,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.17,50,,59.672,percent of total billed charges,50% of total billed charges,3.3,31.95,,9.528,percent of total billed charges,31.95% of total billed charges,3.3,31.95,,9.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.93,38,,3.144,percent of total billed charges,38% of total billed charges,4.13,40,,11.928,percent of total billed charges,40% of total billed charges,3.3,8.78,
galantamine 4 mg Tab [FMC],2570778,CDM,250,RC,,,OUTPATIENT,1,EA,8.83,5.298,,7.51,85,,6.008,Percent of total billed charges,85% of total billed charges,4.42,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.42,50,,4.68,percent of total billed charges,50% of total billed charges,2.82,31.95,,9.528,percent of total billed charges,31.95% of total billed charges,2.82,31.95,,9.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.36,38,,2.688,percent of total billed charges,38% of total billed charges,3.53,40,,11.936,percent of total billed charges,40% of total billed charges,2.82,7.51,
galantamine 4 mg Tab [FMC],2570778,CDM,250,RC,,,OUTPATIENT,1,EA,10.35,6.21,,8.8,85,,7.04,Percent of total billed charges,85% of total billed charges,5.18,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.18,50,,64.2,percent of total billed charges,50% of total billed charges,3.31,31.95,,9.144,percent of total billed charges,31.95% of total billed charges,3.31,31.95,,9.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.93,38,,3.144,percent of total billed charges,38% of total billed charges,4.14,40,,11.456,percent of total billed charges,40% of total billed charges,3.31,8.8,
galantamine 4 mg Tab [FMC],2570778,CDM,250,RC,,,OUTPATIENT,1,EA,10.34,6.204,,8.79,85,,7.032,Percent of total billed charges,85% of total billed charges,5.17,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.17,50,,45.504,percent of total billed charges,50% of total billed charges,3.3,31.95,,8.504,percent of total billed charges,31.95% of total billed charges,3.3,31.95,,8.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.93,38,,3.144,percent of total billed charges,38% of total billed charges,4.14,40,,10.648,percent of total billed charges,40% of total billed charges,3.3,8.79,
magnesium hydroxide 24% Oral Conc 10 mL [FMC],2570786,CDM,250,RC,,,OUTPATIENT,10,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.296,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
magnesium hydroxide 24% Oral Conc 10 mL [FMC],2570786,CDM,250,RC,,,OUTPATIENT,10,ML,11.29,6.774,,9.6,85,,7.68,Percent of total billed charges,85% of total billed charges,5.65,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.65,50,,1.848,percent of total billed charges,50% of total billed charges,3.61,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,3.61,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.29,38,,3.432,percent of total billed charges,38% of total billed charges,4.52,40,,1.288,percent of total billed charges,40% of total billed charges,3.61,9.6,
methadone 5 mg Tab [FMC],2570794,CDM,250,RC,S0109,HCPCS,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,0.41,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,1.312,fee schedule,136.60% of BCBS custom fee schedule,1.41,35.15,,1.032,percent of total billed charges,35.15% of total billed charges,44.73,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.28,31.95,,1.288,percent of total billed charges,31.95% of total billed charges,0.41,44.73,
darifenacin 7.5 mg ER Tab [FMC],2570810,CDM,250,RC,,,OUTPATIENT,1,EA,27.47,16.482,,23.35,85,,18.68,Percent of total billed charges,85% of total billed charges,13.74,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.74,50,,5307.84,percent of total billed charges,50% of total billed charges,8.78,31.95,,62.888,percent of total billed charges,31.95% of total billed charges,8.78,31.95,,44.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.44,38,,8.352,percent of total billed charges,38% of total billed charges,10.99,40,,57.168,percent of total billed charges,40% of total billed charges,8.78,23.35,
darifenacin 7.5 mg ER Tab [FMC],2570810,CDM,250,RC,,,OUTPATIENT,1,EA,27.47,16.482,,23.35,85,,18.68,Percent of total billed charges,85% of total billed charges,13.74,50,,3.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.74,50,,7.792,percent of total billed charges,50% of total billed charges,8.78,31.95,,59.952,percent of total billed charges,31.95% of total billed charges,8.78,31.95,,45.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.44,38,,8.352,percent of total billed charges,38% of total billed charges,10.99,40,,54.496,percent of total billed charges,40% of total billed charges,8.78,23.35,
pneumococcal 23-valent vaccine Inj Sol 0 mL [FMC],2570869,CDM,250,RC,,,OUTPATIENT,0.5,ML,456.62,273.972,,388.13,85,,310.504,Percent of total billed charges,85% of total billed charges,228.31,50,,108,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,228.31,50,,7.936,percent of total billed charges,50% of total billed charges,145.89,31.95,,51.544,percent of total billed charges,31.95% of total billed charges,145.89,31.95,,45.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,173.52,38,,138.816,percent of total billed charges,38% of total billed charges,182.65,40,,46.848,percent of total billed charges,40% of total billed charges,145.89,388.13,
pneumococcal 23-valent vaccine Inj Sol 0 mL [FMC],2570869,CDM,250,RC,,,OUTPATIENT,0.5,ML,456.62,273.972,,388.13,85,,310.504,Percent of total billed charges,85% of total billed charges,228.31,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,228.31,50,,19.36,percent of total billed charges,50% of total billed charges,145.89,31.95,,35.96,percent of total billed charges,31.95% of total billed charges,145.89,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,173.52,38,,138.816,percent of total billed charges,38% of total billed charges,182.65,40,,32.688,percent of total billed charges,40% of total billed charges,145.89,388.13,
antivenin (Crotalidae) polyvalent Inj Sol [FMC],2570885,CDM,250,RC,J0840,HCPCS,OUTPATIENT,1,EA,12472.2,7483.32,,10601.37,85,,8481.096,Percent of total billed charges,85% of total billed charges,3120.09,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3120.09,136.6,,30.696,fee schedule,136.60% of BCBS custom fee schedule,4383.98,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,3984.87,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4739.44,38,,3791.552,percent of total billed charges,38% of total billed charges,3984.87,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,3120.09,10601.37,
pregabalin 50 mg oral capsule [FMC],2571016,CDM,250,RC,,,OUTPATIENT,1,EA,38.64,23.184,,32.84,85,,26.272,Percent of total billed charges,85% of total billed charges,19.32,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.32,50,,40.432,percent of total billed charges,50% of total billed charges,12.35,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,12.35,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.68,38,,11.744,percent of total billed charges,38% of total billed charges,15.46,40,,0.96,percent of total billed charges,40% of total billed charges,12.35,32.84,
pregabalin 50 mg oral capsule [FMC],2571016,CDM,250,RC,,,OUTPATIENT,1,EA,5.25,3.15,,4.46,85,,3.568,Percent of total billed charges,85% of total billed charges,2.63,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.63,50,,4.8,percent of total billed charges,50% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2,38,,1.6,percent of total billed charges,38% of total billed charges,2.1,40,,0.96,percent of total billed charges,40% of total billed charges,1.68,4.46,
pregabalin 50 mg oral capsule [FMC],2571016,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.704,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,4.64,percent of total billed charges,40% of total billed charges,1.28,3.4,
camphor-menthol topical 9%-1.3% Oin 28 gm[FMC],2571065,CDM,250,RC,,,OUTPATIENT,28,EA,6.31,3.786,,5.36,85,,4.288,Percent of total billed charges,85% of total billed charges,3.16,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.16,50,,5.336,percent of total billed charges,50% of total billed charges,2.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.02,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.4,38,,1.92,percent of total billed charges,38% of total billed charges,2.52,40,,0.96,percent of total billed charges,40% of total billed charges,2.02,5.36,
fluPHENAZine decanoate 25 mg/mL Inj Sol [FMC],2571123,CDM,250,RC,J2680,HCPCS,OUTPATIENT,5,ML,525.56,315.336,,446.73,85,,357.384,Percent of total billed charges,85% of total billed charges,14.83,136.6,,29.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.83,136.6,,14.04,fee schedule,136.60% of BCBS custom fee schedule,184.73,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,44.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,199.71,38,,159.768,percent of total billed charges,38% of total billed charges,167.92,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,14.83,446.73,
fluPHENAZine decanoate 25 mg/mL Inj Sol [FMC],2571123,CDM,250,RC,J2680,HCPCS,OUTPATIENT,5,ML,547.46,328.476,,465.34,85,,372.272,Percent of total billed charges,85% of total billed charges,14.83,136.6,,25.144,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.83,136.6,,13.352,fee schedule,136.60% of BCBS custom fee schedule,192.43,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,44.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,208.03,38,,166.424,percent of total billed charges,38% of total billed charges,174.91,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,14.83,465.34,
fentaNYL 0.05 mg/mL Inj 5 mL Sol [FMC],2571131,CDM,250,RC,J3010,HCPCS,OUTPATIENT,5,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,7.528,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,44.73,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.28,44.73,
fentaNYL 0.05 mg/mL Inj 5 mL Sol [FMC],2571131,CDM,250,RC,J3010,HCPCS,OUTPATIENT,5,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,3.952,percent of total billed charges,35.15% of total billed charges,45.34,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,1.28,45.34,
fentaNYL 0.05 mg/mL Inj 5 mL Sol [FMC],2571131,CDM,250,RC,J3010,HCPCS,OUTPATIENT,5,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,15.784,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,7.336,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,1.64,percent of total billed charges,35.15% of total billed charges,45.37,31.95,,1.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,1.28,45.37,
fentaNYL 0.05 mg/mL Inj 5 mL Sol [FMC],2571131,CDM,250,RC,J3010,HCPCS,OUTPATIENT,5,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,13.656,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,1.592,percent of total billed charges,35.15% of total billed charges,47.29,31.95,,1.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,2,percent of total billed charges,31.95% of total billed charges,1.28,47.29,
PHENobarbital 32.4 mg Tab [FMC],2571164,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,10,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.736,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,2.176,percent of total billed charges,40% of total billed charges,1.28,3.4,
PHENobarbital 32.4 mg Tab [FMC],2571164,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,15.472,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.736,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,2.176,percent of total billed charges,40% of total billed charges,1.28,3.4,
"nystatin Top 100,000 units/g Pwdr [FMC]",2571339,CDM,250,RC,,,OUTPATIENT,15,EA,89.25,53.55,,75.86,85,,60.688,Percent of total billed charges,85% of total billed charges,44.63,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.63,50,,9.008,percent of total billed charges,50% of total billed charges,28.52,31.95,,1.736,percent of total billed charges,31.95% of total billed charges,28.52,31.95,,1.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.92,38,,27.136,percent of total billed charges,38% of total billed charges,35.7,40,,2.176,percent of total billed charges,40% of total billed charges,28.52,75.86,
"nystatin Top 100,000 units/g Pwdr [FMC]",2571339,CDM,250,RC,,,OUTPATIENT,15,EA,71.34,42.804,,60.64,85,,48.512,Percent of total billed charges,85% of total billed charges,35.67,50,,10.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.67,50,,5.608,percent of total billed charges,50% of total billed charges,22.79,31.95,,331.28,percent of total billed charges,31.95% of total billed charges,22.79,31.95,,331.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.11,38,,21.688,percent of total billed charges,38% of total billed charges,28.54,40,,414.752,percent of total billed charges,40% of total billed charges,22.79,60.64,
"nystatin Top 100,000 units/g Pwdr [FMC]",2571339,CDM,250,RC,,,OUTPATIENT,15,EA,121.74,73.044,,103.48,85,,82.784,Percent of total billed charges,85% of total billed charges,60.87,50,,17.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,60.87,50,,51.408,percent of total billed charges,50% of total billed charges,38.9,31.95,,331.28,percent of total billed charges,31.95% of total billed charges,38.9,31.95,,331.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.26,38,,37.008,percent of total billed charges,38% of total billed charges,48.7,40,,414.752,percent of total billed charges,40% of total billed charges,38.9,103.48,
"nystatin Top 100,000 units/g Pwdr [FMC]",2571339,CDM,250,RC,,,OUTPATIENT,15,EA,123.34,74.004,,104.84,85,,83.872,Percent of total billed charges,85% of total billed charges,61.67,50,,15,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,61.67,50,,51.408,percent of total billed charges,50% of total billed charges,39.41,31.95,,6.808,percent of total billed charges,31.95% of total billed charges,39.41,31.95,,6.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.87,38,,37.496,percent of total billed charges,38% of total billed charges,49.34,40,,8.52,percent of total billed charges,40% of total billed charges,39.41,104.84,
"nystatin Top 100,000 units/g Pwdr [FMC]",2571339,CDM,250,RC,,,OUTPATIENT,15,EA,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,45.5,50,,20.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.5,50,,51.48,percent of total billed charges,50% of total billed charges,29.07,31.95,,12.936,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,12.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.58,38,,27.664,percent of total billed charges,38% of total billed charges,36.4,40,,16.2,percent of total billed charges,40% of total billed charges,29.07,77.35,
pregabalin 25 mg oral capsule [FMC],2571347,CDM,250,RC,,,OUTPATIENT,1,EA,15.7,9.42,,13.35,85,,10.68,Percent of total billed charges,85% of total billed charges,7.85,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.85,50,,1.2,percent of total billed charges,50% of total billed charges,5.02,31.95,,4.424,percent of total billed charges,31.95% of total billed charges,5.02,31.95,,4.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.97,38,,4.776,percent of total billed charges,38% of total billed charges,6.28,40,,5.536,percent of total billed charges,40% of total billed charges,5.02,13.35,
pregabalin 25 mg oral capsule [FMC],2571347,CDM,250,RC,,,OUTPATIENT,1,EA,15.7,9.42,,13.35,85,,10.68,Percent of total billed charges,85% of total billed charges,7.85,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.85,50,,1.2,percent of total billed charges,50% of total billed charges,5.02,31.95,,8.288,percent of total billed charges,31.95% of total billed charges,5.02,31.95,,8.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.97,38,,4.776,percent of total billed charges,38% of total billed charges,6.28,40,,10.376,percent of total billed charges,40% of total billed charges,5.02,13.35,
pregabalin 25 mg oral capsule [FMC],2571347,CDM,250,RC,,,OUTPATIENT,1,EA,5.25,3.15,,4.46,85,,3.568,Percent of total billed charges,85% of total billed charges,2.63,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.63,50,,1.2,percent of total billed charges,50% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.68,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2,38,,1.6,percent of total billed charges,38% of total billed charges,2.1,40,,0.96,percent of total billed charges,40% of total billed charges,1.68,4.46,
pregabalin 25 mg oral capsule [FMC],2571347,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.368,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
levofloxacin 750 mg/150 mL IVPB Premix Sol [FMC],2571396,CDM,250,RC,J1956,HCPCS,OUTPATIENT,150,ML,51.17,30.702,,43.49,85,,34.792,Percent of total billed charges,85% of total billed charges,1.39,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,67.528,fee schedule,136.60% of BCBS custom fee schedule,17.99,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,16.35,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.44,38,,15.552,percent of total billed charges,38% of total billed charges,16.35,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1.39,43.49,
levofloxacin 750 mg/150 mL IVPB Premix Sol [FMC],2571396,CDM,250,RC,J1956,HCPCS,OUTPATIENT,150,ML,42.9,25.74,,36.47,85,,29.176,Percent of total billed charges,85% of total billed charges,1.39,136.6,,14.432,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,67.528,fee schedule,136.60% of BCBS custom fee schedule,15.08,35.15,,224.376,fee schedule,35.15% of LA custom fee schedule,13.71,31.95,,224.376,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.3,38,,13.04,percent of total billed charges,38% of total billed charges,13.71,31.95,,280.904,Fee Schedule,31.95% of LA custom fee schedule,1.39,36.47,
levofloxacin 750 mg/150 mL IVPB Premix Sol [FMC],2571396,CDM,250,RC,J1956,HCPCS,OUTPATIENT,150,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,32.688,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,46.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,1.39,30.6,
levofloxacin 750 mg/150 mL IVPB Premix Sol [FMC],2571396,CDM,250,RC,J1956,HCPCS,OUTPATIENT,150,ML,44.69,26.814,,37.99,85,,30.392,Percent of total billed charges,85% of total billed charges,1.39,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,11.168,fee schedule,136.60% of BCBS custom fee schedule,15.71,35.15,,28.72,fee schedule,35.15% of LA custom fee schedule,14.28,31.95,,46.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.98,38,,13.584,percent of total billed charges,38% of total billed charges,14.28,31.95,,26.104,Fee Schedule,31.95% of LA custom fee schedule,1.39,37.99,
levofloxacin 750 mg/150 mL IVPB Premix Sol [FMC],2571396,CDM,250,RC,J1956,HCPCS,OUTPATIENT,150,ML,50.7,30.42,,43.1,85,,34.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,45.304,fee schedule,136.60% of BCBS custom fee schedule,17.82,35.15,,3.616,fee schedule,35.15% of LA custom fee schedule,16.2,31.95,,3.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.27,38,,15.416,percent of total billed charges,38% of total billed charges,16.2,31.95,,4.528,Fee Schedule,31.95% of LA custom fee schedule,1.39,43.1,
levofloxacin 750 mg/150 mL IVPB Premix Sol [FMC],2571396,CDM,250,RC,J1956,HCPCS,OUTPATIENT,150,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,6.376,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,2.064,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,2.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,2.576,Fee Schedule,31.95% of LA custom fee schedule,1.39,30.6,
fenofibrate 48 mg Tab [FMC],2571438,CDM,250,RC,,,OUTPATIENT,1,EA,6.21,3.726,,5.28,85,,4.224,Percent of total billed charges,85% of total billed charges,3.11,50,,3.32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.11,50,,6.568,percent of total billed charges,50% of total billed charges,1.98,31.95,,3.816,percent of total billed charges,31.95% of total billed charges,1.98,31.95,,3.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.36,38,,1.888,percent of total billed charges,38% of total billed charges,2.48,40,,4.776,percent of total billed charges,40% of total billed charges,1.98,5.28,
fenofibrate 48 mg Tab [FMC],2571438,CDM,250,RC,,,OUTPATIENT,1,EA,6.21,3.726,,5.28,85,,4.224,Percent of total billed charges,85% of total billed charges,3.11,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.11,50,,6.376,percent of total billed charges,50% of total billed charges,1.98,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.98,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.36,38,,1.888,percent of total billed charges,38% of total billed charges,2.48,40,,1.92,percent of total billed charges,40% of total billed charges,1.98,5.28,
doxazosin 1 mg Tab [FMC],2571495,CDM,250,RC,,,OUTPATIENT,1,EA,3.59,2.154,,3.05,85,,2.44,Percent of total billed charges,85% of total billed charges,1.8,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.8,50,,1.2,percent of total billed charges,50% of total billed charges,1.15,31.95,,11.496,percent of total billed charges,31.95% of total billed charges,1.15,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.36,38,,1.088,percent of total billed charges,38% of total billed charges,1.44,40,,10.448,percent of total billed charges,40% of total billed charges,1.15,3.05,
doxazosin 1 mg Tab [FMC],2571495,CDM,250,RC,,,OUTPATIENT,1,EA,3.48,2.088,,2.96,85,,2.368,Percent of total billed charges,85% of total billed charges,1.74,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.74,50,,1.2,percent of total billed charges,50% of total billed charges,1.11,31.95,,8.2,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,46.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.32,38,,1.056,percent of total billed charges,38% of total billed charges,1.39,40,,7.456,percent of total billed charges,40% of total billed charges,1.11,2.96,
enoxaparin 40 mg/0.4 mL SC Sol [FMC],2571503,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.4,ML,115.97,69.582,,98.57,85,,78.856,Percent of total billed charges,85% of total billed charges,1,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,40.76,35.15,,8.776,fee schedule,35.15% of LA custom fee schedule,37.05,31.95,,46.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,44.07,38,,35.256,percent of total billed charges,38% of total billed charges,37.05,31.95,,7.976,Fee Schedule,31.95% of LA custom fee schedule,1,98.57,
enoxaparin 40 mg/0.4 mL SC Sol [FMC],2571503,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.4,ML,129,77.4,,109.65,85,,87.72,Percent of total billed charges,85% of total billed charges,1,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,45.34,35.15,,8.832,fee schedule,35.15% of LA custom fee schedule,41.22,31.95,,46.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,49.02,38,,39.216,percent of total billed charges,38% of total billed charges,41.22,31.95,,8.024,Fee Schedule,31.95% of LA custom fee schedule,1,109.65,
enoxaparin 40 mg/0.4 mL SC Sol [FMC],2571503,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.4,ML,105.53,63.318,,89.7,85,,71.76,Percent of total billed charges,85% of total billed charges,1,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,2.68,fee schedule,136.60% of BCBS custom fee schedule,37.09,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,33.72,31.95,,46.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,40.1,38,,32.08,percent of total billed charges,38% of total billed charges,33.72,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,1,89.7,
enoxaparin 40 mg/0.4 mL SC Sol [FMC],2571503,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.4,ML,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,1,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,2.656,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,7.48,31.95,,46.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,1,19.89,
enoxaparin 40 mg/0.4 mL SC Sol [FMC],2571503,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.4,ML,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,1,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,2.68,fee schedule,136.60% of BCBS custom fee schedule,8.23,35.15,,10.12,fee schedule,35.15% of LA custom fee schedule,7.48,31.95,,46.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,7.48,31.95,,9.2,Fee Schedule,31.95% of LA custom fee schedule,1,19.89,
enoxaparin 40 mg/0.4 mL SC Sol [FMC],2571503,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.4,ML,15.95,9.57,,13.56,85,,10.848,Percent of total billed charges,85% of total billed charges,1,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1.696,fee schedule,136.60% of BCBS custom fee schedule,5.61,35.15,,6.672,fee schedule,35.15% of LA custom fee schedule,5.1,31.95,,6.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.06,38,,4.848,percent of total billed charges,38% of total billed charges,5.1,31.95,,8.352,Fee Schedule,31.95% of LA custom fee schedule,1,13.56,
insulin detemir 100 units/mL SC Sol [FMC],2571560,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,120.18,72.108,,102.15,85,,81.72,Percent of total billed charges,85% of total billed charges,0.76,136.6,,37.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,7.08,fee schedule,136.60% of BCBS custom fee schedule,42.24,35.15,,6.68,fee schedule,35.15% of LA custom fee schedule,38.4,31.95,,6.68,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,45.67,38,,36.536,percent of total billed charges,38% of total billed charges,38.4,31.95,,8.36,Fee Schedule,31.95% of LA custom fee schedule,0.76,102.15,
potassium chloride 8 mEq ER Tab [FMC],2571578,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,8.352,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 8 mEq ER Tab [FMC],2571578,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.024,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.68,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,8.36,percent of total billed charges,40% of total billed charges,0.96,2.55,
potassium chloride 8 mEq ER Tab [FMC],2571578,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,7.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.928,percent of total billed charges,40% of total billed charges,0.96,2.55,
solifenacin 10 mg Tab [FMC],2571602,CDM,250,RC,,,OUTPATIENT,1,EA,28.75,17.25,,24.44,85,,19.552,Percent of total billed charges,85% of total billed charges,14.38,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.38,50,,6.464,percent of total billed charges,50% of total billed charges,9.19,31.95,,7.984,percent of total billed charges,31.95% of total billed charges,9.19,31.95,,7.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.93,38,,8.744,percent of total billed charges,38% of total billed charges,11.5,40,,10,percent of total billed charges,40% of total billed charges,9.19,24.44,
solifenacin 10 mg Tab [FMC],2571602,CDM,250,RC,,,OUTPATIENT,1,EA,47.61,28.566,,40.47,85,,32.376,Percent of total billed charges,85% of total billed charges,23.81,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.81,50,,7.256,percent of total billed charges,50% of total billed charges,15.21,31.95,,5.296,percent of total billed charges,31.95% of total billed charges,15.21,31.95,,5.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.09,38,,14.472,percent of total billed charges,38% of total billed charges,19.04,40,,6.632,percent of total billed charges,40% of total billed charges,15.21,40.47,
solifenacin 10 mg Tab [FMC],2571602,CDM,250,RC,,,OUTPATIENT,1,EA,45.08,27.048,,38.32,85,,30.656,Percent of total billed charges,85% of total billed charges,22.54,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.54,50,,17.72,percent of total billed charges,50% of total billed charges,14.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,14.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.13,38,,13.704,percent of total billed charges,38% of total billed charges,18.03,40,,0.96,percent of total billed charges,40% of total billed charges,14.4,38.32,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,26.91,16.146,,22.87,85,,18.296,Percent of total billed charges,85% of total billed charges,1.34,136.6,,20.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,9.46,35.15,,0.864,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,0.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.23,38,,8.184,percent of total billed charges,38% of total billed charges,8.6,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,1.34,47.93,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,33.66,20.196,,28.61,85,,22.888,Percent of total billed charges,85% of total billed charges,1.34,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,11.83,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.79,38,,10.232,percent of total billed charges,38% of total billed charges,10.75,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.34,47.93,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,47.13,28.278,,40.06,85,,32.048,Percent of total billed charges,85% of total billed charges,1.34,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,16.57,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.91,38,,14.328,percent of total billed charges,38% of total billed charges,15.06,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.34,47.93,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,47.13,28.278,,40.06,85,,32.048,Percent of total billed charges,85% of total billed charges,1.34,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,77.224,fee schedule,136.60% of BCBS custom fee schedule,16.57,35.15,,20.376,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,46.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.91,38,,14.328,percent of total billed charges,38% of total billed charges,15.06,31.95,,18.52,percent of total billed charges,31.95% of total billed charges,1.34,47.93,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,36.08,21.648,,30.67,85,,24.536,Percent of total billed charges,85% of total billed charges,1.34,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,19.64,fee schedule,136.60% of BCBS custom fee schedule,12.68,35.15,,21.12,percent of total billed charges,35.15% of total billed charges,50.8,31.95,,47.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.71,38,,10.968,percent of total billed charges,38% of total billed charges,11.53,31.95,,19.2,percent of total billed charges,31.95% of total billed charges,1.34,50.8,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,36.08,21.648,,30.67,85,,24.536,Percent of total billed charges,85% of total billed charges,1.34,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,6.744,fee schedule,136.60% of BCBS custom fee schedule,12.68,35.15,,20.376,percent of total billed charges,35.15% of total billed charges,50.8,31.95,,47.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.71,38,,10.968,percent of total billed charges,38% of total billed charges,11.53,31.95,,18.52,percent of total billed charges,31.95% of total billed charges,1.34,50.8,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.34,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,17.8,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,50.8,31.95,,47.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.34,50.8,
piperacillin-tazobactam 2 g-0.25 g IV Inj [FMC],2571628,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,13.4,8.04,,11.39,85,,9.112,Percent of total billed charges,85% of total billed charges,1.34,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,4.71,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,50.8,31.95,,49.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.09,38,,4.072,percent of total billed charges,38% of total billed charges,4.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1.34,50.8,
metoprolol tartrate 25 mg UD Tab [FMC],2571644,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.456,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.32,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol tartrate 25 mg UD Tab [FMC],2571644,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.248,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.816,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol tartrate 25 mg UD Tab [FMC],2571644,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.728,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.672,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol tartrate 25 mg UD Tab [FMC],2571644,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,7.096,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.864,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.08,percent of total billed charges,40% of total billed charges,0.96,2.55,
metoprolol tartrate 25 mg UD Tab [FMC],2571644,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
oseltamivir 6 mg/mL REC [FMC],2571651,CDM,250,RC,,,OUTPATIENT,60,ML,592.35,355.41,,503.5,85,,402.8,Percent of total billed charges,85% of total billed charges,296.18,50,,136.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,296.18,50,,1.6,percent of total billed charges,50% of total billed charges,189.26,31.95,,12.024,percent of total billed charges,31.95% of total billed charges,189.26,31.95,,12.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,225.09,38,,180.072,percent of total billed charges,38% of total billed charges,236.94,40,,15.056,percent of total billed charges,40% of total billed charges,189.26,503.5,
oseltamivir 6 mg/mL REC [FMC],2571651,CDM,250,RC,,,OUTPATIENT,60,ML,532.51,319.506,,452.63,85,,362.104,Percent of total billed charges,85% of total billed charges,266.26,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,266.26,50,,1.2,percent of total billed charges,50% of total billed charges,170.14,31.95,,9,percent of total billed charges,31.95% of total billed charges,170.14,31.95,,9,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,202.35,38,,161.88,percent of total billed charges,38% of total billed charges,213,40,,11.272,percent of total billed charges,40% of total billed charges,170.14,452.63,
oseltamivir 6 mg/mL REC [FMC],2571651,CDM,250,RC,,,OUTPATIENT,60,ML,532.16,319.296,,452.34,85,,361.872,Percent of total billed charges,85% of total billed charges,266.08,50,,20.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,266.08,50,,1.2,percent of total billed charges,50% of total billed charges,170.03,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,170.03,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,202.22,38,,161.776,percent of total billed charges,38% of total billed charges,212.86,40,,0.96,percent of total billed charges,40% of total billed charges,170.03,452.34,
oseltamivir 6 mg/mL REC [FMC],2571651,CDM,250,RC,,,OUTPATIENT,60,ML,533.1,319.86,,453.14,85,,362.512,Percent of total billed charges,85% of total billed charges,266.55,50,,105.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,266.55,50,,1.2,percent of total billed charges,50% of total billed charges,170.33,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,170.33,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,202.58,38,,162.064,percent of total billed charges,38% of total billed charges,213.24,40,,0.96,percent of total billed charges,40% of total billed charges,170.33,453.14,
donepezil 10 mg Tab [FMC],2571669,CDM,250,RC,,,OUTPATIENT,1,EA,20.7,12.42,,17.6,85,,14.08,Percent of total billed charges,85% of total billed charges,10.35,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.35,50,,118.336,percent of total billed charges,50% of total billed charges,6.61,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.61,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.87,38,,6.296,percent of total billed charges,38% of total billed charges,8.28,40,,0.96,percent of total billed charges,40% of total billed charges,6.61,17.6,
donepezil 10 mg Tab [FMC],2571669,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,97.504,percent of total billed charges,50% of total billed charges,0.96,31.95,,23.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,23.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,29.952,percent of total billed charges,40% of total billed charges,0.96,2.55,
donepezil 10 mg Tab [FMC],2571669,CDM,250,RC,,,OUTPATIENT,1,EA,25.32,15.192,,21.52,85,,17.216,Percent of total billed charges,85% of total billed charges,12.66,50,,90.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.66,50,,84.24,percent of total billed charges,50% of total billed charges,8.09,31.95,,23.656,percent of total billed charges,31.95% of total billed charges,8.09,31.95,,23.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.62,38,,7.696,percent of total billed charges,38% of total billed charges,10.13,40,,29.616,percent of total billed charges,40% of total billed charges,8.09,21.52,
donepezil 10 mg Tab [FMC],2571669,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,0.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,70.192,percent of total billed charges,50% of total billed charges,0.96,31.95,,25.752,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,25.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,32.24,percent of total billed charges,40% of total billed charges,0.96,2.55,
medroxyPROGESTERone 150 mg/mL IM Susp [FMC],2571693,CDM,250,RC,J1050,HCPCS,OUTPATIENT,1,ML,205.27,123.162,,174.48,85,,139.584,Percent of total billed charges,85% of total billed charges,0.55,136.6,,20.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.55,136.6,,106.456,fee schedule,136.60% of BCBS custom fee schedule,72.15,35.15,,2018.256,fee schedule,35.15% of LA custom fee schedule,65.58,31.95,,49.664,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,78,38,,62.4,percent of total billed charges,38% of total billed charges,65.58,31.95,,1834.52,Fee Schedule,31.95% of LA custom fee schedule,0.55,174.48,
medroxyPROGESTERone 150 mg/mL IM Susp [FMC],2571693,CDM,250,RC,J1050,HCPCS,OUTPATIENT,1,ML,318.01,190.806,,270.31,85,,216.248,Percent of total billed charges,85% of total billed charges,0.55,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.55,136.6,,165.104,fee schedule,136.60% of BCBS custom fee schedule,111.78,35.15,,3434.912,fee schedule,35.15% of LA custom fee schedule,101.6,31.95,,49.664,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,120.84,38,,96.672,percent of total billed charges,38% of total billed charges,101.6,31.95,,3122.2,Fee Schedule,31.95% of LA custom fee schedule,0.55,270.31,
medroxyPROGESTERone 150 mg/mL IM Susp [FMC],2571693,CDM,250,RC,J1050,HCPCS,OUTPATIENT,1,ML,175.5,105.3,,149.18,85,,119.344,Percent of total billed charges,85% of total billed charges,0.55,136.6,,27.104,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.55,136.6,,275.392,fee schedule,136.60% of BCBS custom fee schedule,61.69,35.15,,9.728,fee schedule,35.15% of LA custom fee schedule,56.07,31.95,,9.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,66.69,38,,53.352,percent of total billed charges,38% of total billed charges,56.07,31.95,,12.176,Fee Schedule,31.95% of LA custom fee schedule,0.55,149.18,
ceFAZolin 1 g/50 mL IVPB Premix Soln [FMC],2571701,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,ML,51.17,30.702,,43.49,85,,34.792,Percent of total billed charges,85% of total billed charges,1.09,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,308.256,fee schedule,136.60% of BCBS custom fee schedule,17.99,35.15,,9.2,fee schedule,35.15% of LA custom fee schedule,16.35,31.95,,9.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.44,38,,15.552,percent of total billed charges,38% of total billed charges,16.35,31.95,,11.52,Fee Schedule,31.95% of LA custom fee schedule,1.09,43.49,
misoprostol 200 mcg Tab [FMC],2571727,CDM,250,RC,,,OUTPATIENT,1,EA,4.65,2.79,,3.95,85,,3.16,Percent of total billed charges,85% of total billed charges,2.33,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.33,50,,10.024,percent of total billed charges,50% of total billed charges,1.49,31.95,,169.464,percent of total billed charges,31.95% of total billed charges,1.49,31.95,,169.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.77,38,,1.416,percent of total billed charges,38% of total billed charges,1.86,40,,212.16,percent of total billed charges,40% of total billed charges,1.49,3.95,
misoprostol 200 mcg Tab [FMC],2571727,CDM,250,RC,,,OUTPATIENT,1,EA,8.86,5.316,,7.53,85,,6.024,Percent of total billed charges,85% of total billed charges,4.43,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.43,50,,4563.272,percent of total billed charges,50% of total billed charges,2.83,31.95,,543.28,percent of total billed charges,31.95% of total billed charges,2.83,31.95,,543.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.37,38,,2.696,percent of total billed charges,38% of total billed charges,3.54,40,,680.16,percent of total billed charges,40% of total billed charges,2.83,7.53,
misoprostol 200 mcg Tab [FMC],2571727,CDM,250,RC,,,OUTPATIENT,1,EA,3.9,2.34,,3.32,85,,2.656,Percent of total billed charges,85% of total billed charges,1.95,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.95,50,,77.36,percent of total billed charges,50% of total billed charges,1.25,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.25,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.48,38,,1.184,percent of total billed charges,38% of total billed charges,1.56,40,,0.96,percent of total billed charges,40% of total billed charges,1.25,3.32,
theophylline 100 mg/24 hours Oral ER Cap [FMC],2571743,CDM,250,RC,,,OUTPATIENT,1,EA,11.37,6.822,,9.66,85,,7.728,Percent of total billed charges,85% of total billed charges,5.69,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.69,50,,6.584,percent of total billed charges,50% of total billed charges,3.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.63,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.32,38,,3.456,percent of total billed charges,38% of total billed charges,4.55,40,,0.96,percent of total billed charges,40% of total billed charges,3.63,9.66,
carbidopa-levodopa 25 mg-100 mg ER Tab [FMC],2571750,CDM,250,RC,,,OUTPATIENT,1,EA,3.03,1.818,,2.58,85,,2.064,Percent of total billed charges,85% of total billed charges,1.52,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.52,50,,14.176,percent of total billed charges,50% of total billed charges,0.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.97,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.15,38,,0.92,percent of total billed charges,38% of total billed charges,1.21,40,,0.96,percent of total billed charges,40% of total billed charges,0.97,2.58,
carbidopa-levodopa 25 mg-100 mg ER Tab [FMC],2571750,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,60.176,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
clarithromycin 125 mg/5 mL Oral Liq [FMC],2571768,CDM,250,RC,,,OUTPATIENT,50,ML,91.03,54.618,,77.38,85,,61.904,Percent of total billed charges,85% of total billed charges,45.52,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.52,50,,4.8,percent of total billed charges,50% of total billed charges,29.08,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,29.08,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.59,38,,27.672,percent of total billed charges,38% of total billed charges,36.41,40,,6.232,percent of total billed charges,40% of total billed charges,29.08,77.38,
mometasone Top 0.1% Crm [FMC],2571776,CDM,250,RC,,,OUTPATIENT,15,EA,159.25,95.55,,135.36,85,,108.288,Percent of total billed charges,85% of total billed charges,79.63,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79.63,50,,7.928,percent of total billed charges,50% of total billed charges,50.88,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,50.88,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.52,38,,48.416,percent of total billed charges,38% of total billed charges,63.7,40,,6.232,percent of total billed charges,40% of total billed charges,50.88,135.36,
mometasone Top 0.1% Crm [FMC],2571776,CDM,250,RC,,,OUTPATIENT,15,EA,86.94,52.164,,73.9,85,,59.12,Percent of total billed charges,85% of total billed charges,43.47,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,43.47,50,,5.528,percent of total billed charges,50% of total billed charges,27.78,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,27.78,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.04,38,,26.432,percent of total billed charges,38% of total billed charges,34.78,40,,6.232,percent of total billed charges,40% of total billed charges,27.78,73.9,
mometasone Top 0.1% Crm [FMC],2571776,CDM,250,RC,,,OUTPATIENT,15,EA,87.75,52.65,,74.59,85,,59.672,Percent of total billed charges,85% of total billed charges,43.88,50,,34.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,43.88,50,,39,percent of total billed charges,50% of total billed charges,28.04,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,28.04,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.35,38,,26.68,percent of total billed charges,38% of total billed charges,35.1,40,,6.24,percent of total billed charges,40% of total billed charges,28.04,74.59,
7 day vaginal cream clotrimazole vaginal cream 1% vag antifungal 45 gm [FMC],2571792,CDM,250,RC,,,OUTPATIENT,45,EA,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,39.816,percent of total billed charges,50% of total billed charges,8.31,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,7.904,percent of total billed charges,38% of total billed charges,10.4,40,,1.04,percent of total billed charges,40% of total billed charges,8.31,22.1,
7 day vaginal cream clotrimazole vaginal cream 1% vag antifungal 45 gm [FMC],2571792,CDM,250,RC,,,OUTPATIENT,45,EA,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,19.5,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.5,50,,42.072,percent of total billed charges,50% of total billed charges,12.46,31.95,,4.432,percent of total billed charges,31.95% of total billed charges,12.46,31.95,,4.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,15.6,40,,5.552,percent of total billed charges,40% of total billed charges,12.46,33.15,
potassium phosphate 3 mmol/mL IV Sol [FMC],2571800,CDM,250,RC,,,OUTPATIENT,15,ML,16.25,9.75,,13.81,85,,11.048,Percent of total billed charges,85% of total billed charges,8.13,50,,76.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.13,50,,64.52,percent of total billed charges,50% of total billed charges,5.19,31.95,,2.928,percent of total billed charges,31.95% of total billed charges,5.19,31.95,,2.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.18,38,,4.944,percent of total billed charges,38% of total billed charges,6.5,40,,3.664,percent of total billed charges,40% of total billed charges,5.19,13.81,
potassium phosphate 3 mmol/mL IV Sol [FMC],2571800,CDM,250,RC,,,OUTPATIENT,15,ML,57.68,34.608,,49.03,85,,39.224,Percent of total billed charges,85% of total billed charges,28.84,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.84,50,,25.184,percent of total billed charges,50% of total billed charges,18.43,31.95,,3.952,percent of total billed charges,31.95% of total billed charges,18.43,31.95,,3.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.92,38,,17.536,percent of total billed charges,38% of total billed charges,23.07,40,,4.944,percent of total billed charges,40% of total billed charges,18.43,49.03,
chondroitin-glucosamine 400 mg-500 mg Tab [FMC],2571826,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,80.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,26.568,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.632,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.296,percent of total billed charges,40% of total billed charges,0.96,2.55,
chondroitin-glucosamine 400 mg-500 mg Cap [FMC],2571826,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.176,percent of total billed charges,40% of total billed charges,0.96,2.55,
chondroitin-glucosamine 400 mg-500 mg Tab [FMC],2571826,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.176,percent of total billed charges,40% of total billed charges,0.96,2.55,
omega-3 polyunsaturated fatty acids 1000 mg Cap [FMC],2571834,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,9.224,percent of total billed charges,50% of total billed charges,0.96,31.95,,24.048,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,24.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,30.112,percent of total billed charges,40% of total billed charges,0.96,2.55,
omega-3 polyunsaturated fatty acids 1000 mg Cap [FMC],2571834,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,98.752,percent of total billed charges,50% of total billed charges,0.96,31.95,,22.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,22.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,28.704,percent of total billed charges,40% of total billed charges,0.96,2.55,
omega-3 polyunsaturated fatty acids 1000 mg Cap [FMC],2571834,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,78.888,percent of total billed charges,50% of total billed charges,0.96,31.95,,22.928,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,22.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,28.704,percent of total billed charges,40% of total billed charges,0.96,2.55,
gentamicin 100 mg/100 mL-NS IV Sol [FMC],2571842,CDM,250,RC,J1580,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.38,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.38,136.6,,94.328,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,1.656,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,1.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,2.08,Fee Schedule,31.95% of LA custom fee schedule,4.38,30.6,
bacitracin/neomycin/polymyxin B Top Oint Pack  [FMC],2571859,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,25.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,59.176,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.656,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,2.08,percent of total billed charges,40% of total billed charges,1.92,5.1,
bacitracin/neomycin/polymyxin B Top Oint Pack  [FMC],2571859,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,129.704,percent of total billed charges,50% of total billed charges,1.92,31.95,,2.8,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,2.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,3.512,percent of total billed charges,40% of total billed charges,1.92,5.1,
bacitracin/neomycin/polymyxin B Top Oint Pack  [FMC],2571859,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,50.76,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,2.08,percent of total billed charges,40% of total billed charges,1.92,5.1,
bacitracin/neomycin/polymyxin B Top Oint Pack  [FMC],2571859,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,14.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.656,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,2.08,percent of total billed charges,40% of total billed charges,1.92,5.1,
hydrocortisone/neomycin/polymyxin B Otic 10 mg-3.5 mg-10000 units per mL Susp [FMC],2571883,CDM,250,RC,,,OUTPATIENT,10,EA,327.21,196.326,,278.13,85,,222.504,Percent of total billed charges,85% of total billed charges,163.61,50,,99.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,163.61,50,,14.4,percent of total billed charges,50% of total billed charges,104.54,31.95,,6.192,percent of total billed charges,31.95% of total billed charges,104.54,31.95,,49.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.34,38,,99.472,percent of total billed charges,38% of total billed charges,130.88,40,,5.624,percent of total billed charges,40% of total billed charges,104.54,278.13,
hydrocortisone/neomycin/polymyxin B Otic 10 mg-3.5 mg-10000 units per mL Susp [FMC],2571883,CDM,250,RC,,,OUTPATIENT,10,EA,100.1,60.06,,85.09,85,,68.072,Percent of total billed charges,85% of total billed charges,50.05,50,,68.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.05,50,,12.36,percent of total billed charges,50% of total billed charges,31.98,31.95,,7.208,percent of total billed charges,31.95% of total billed charges,31.98,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.04,38,,30.432,percent of total billed charges,38% of total billed charges,40.04,40,,6.552,percent of total billed charges,40% of total billed charges,31.98,85.09,
methimazole 10 mg Tab [FMC],2571909,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10.68,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.824,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
methimazole 10 mg Tab [FMC],2571909,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.76,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.776,percent of total billed charges,40% of total billed charges,0.96,2.55,
methIMAzole 10 mg Tab,2571909,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.032,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.48,percent of total billed charges,40% of total billed charges,0.96,2.55,
methIMAzole 10 mg Tab,2571909,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,26.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,14.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,7.208,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,50.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,6.552,percent of total billed charges,40% of total billed charges,0.96,2.55,
levofloxacin 250 mg/50 mL IVPB Premix Sol [FMC],2571917,CDM,250,RC,J1956,HCPCS,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,1.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,8.776,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,526.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,7.976,Fee Schedule,31.95% of LA custom fee schedule,1.39,30.6,
levofloxacin 250 mg/50 mL IVPB Premix Sol [FMC],2571917,CDM,250,RC,J1956,HCPCS,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,8.104,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,6,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,7.512,Fee Schedule,31.95% of LA custom fee schedule,1.39,30.6,
levofloxacin 250 mg/50 mL IVPB Premix Sol [FMC],2571917,CDM,250,RC,J1956,HCPCS,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.39,136.6,,30.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,2.432,fee schedule,35.15% of LA custom fee schedule,11.5,31.95,,2.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.04,Fee Schedule,31.95% of LA custom fee schedule,1.39,30.6,
magnesium sulfate 1 g/100 mL-D5W Sol [FMC],2571925,CDM,250,RC,J3475,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.15,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,14.136,percent of total billed charges,35.15% of total billed charges,53.07,31.95,,14.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,17.696,percent of total billed charges,31.95% of total billed charges,1.15,53.07,
magnesium sulfate 1 g/100 mL-D5W Sol [FMC],2571925,CDM,250,RC,J3475,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.15,136.6,,41.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,15.224,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,21.2,percent of total billed charges,35.15% of total billed charges,53.68,31.95,,21.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,26.544,percent of total billed charges,31.95% of total billed charges,1.15,53.68,
magnesium sulfate 1 g/100 mL-D5W Sol [FMC],2571925,CDM,250,RC,J3475,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,1.15,136.6,,98.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,53.68,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,1.15,53.68,
albumin human 25% IV Sol 100 mL [FMC],2571933,CDM,250,RC,P9047,HCPCS,OUTPATIENT,100,ML,382.66,229.596,,325.26,85,,260.208,Percent of total billed charges,85% of total billed charges,79.76,136.6,,56.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.76,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,134.5,35.15,,6.208,percent of total billed charges,35.15% of total billed charges,54.18,31.95,,6.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.41,38,,116.328,percent of total billed charges,38% of total billed charges,122.26,31.95,,7.776,percent of total billed charges,31.95% of total billed charges,54.18,325.26,
"EPINEPHrine-lidocaine 1:100,000-1% Inj Sol [FMC]",2571958,CDM,250,RC,,,OUTPATIENT,20,ML,14.63,8.778,,12.44,85,,9.952,Percent of total billed charges,85% of total billed charges,7.32,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.32,50,,12,percent of total billed charges,50% of total billed charges,4.67,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4.67,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.56,38,,4.448,percent of total billed charges,38% of total billed charges,5.85,40,,3.84,percent of total billed charges,40% of total billed charges,4.67,12.44,
"EPINEPHrine-lidocaine 1:100,000-1% Inj Sol [FMC]",2571958,CDM,250,RC,,,OUTPATIENT,20,ML,14.74,8.844,,12.53,85,,10.024,Percent of total billed charges,85% of total billed charges,7.37,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.37,50,,14,percent of total billed charges,50% of total billed charges,4.71,31.95,,3.16,percent of total billed charges,31.95% of total billed charges,4.71,31.95,,3.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.6,38,,4.48,percent of total billed charges,38% of total billed charges,5.9,40,,3.952,percent of total billed charges,40% of total billed charges,4.71,12.53,
"EPINEPHrine-lidocaine 1:100,000-1% Inj Sol [FMC]",2571958,CDM,250,RC,,,OUTPATIENT,20,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,42.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,14.4,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,4.864,percent of total billed charges,40% of total billed charges,3.83,10.2,
zolpidem 10 mg Tab [FMC],2572006,CDM,250,RC,,,OUTPATIENT,1,EA,17.54,10.524,,14.91,85,,11.928,Percent of total billed charges,85% of total billed charges,8.77,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.77,50,,14.4,percent of total billed charges,50% of total billed charges,5.6,31.95,,6.856,percent of total billed charges,31.95% of total billed charges,5.6,31.95,,6.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.67,38,,5.336,percent of total billed charges,38% of total billed charges,7.02,40,,8.584,percent of total billed charges,40% of total billed charges,5.6,14.91,
zolpidem 10 mg Tab [FMC],2572006,CDM,250,RC,,,OUTPATIENT,1,EA,15.1,9.06,,12.84,85,,10.272,Percent of total billed charges,85% of total billed charges,7.55,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.55,50,,14.4,percent of total billed charges,50% of total billed charges,4.82,31.95,,17.208,percent of total billed charges,31.95% of total billed charges,4.82,31.95,,17.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.74,38,,4.592,percent of total billed charges,38% of total billed charges,6.04,40,,21.536,percent of total billed charges,40% of total billed charges,4.82,12.84,
zolpidem 10 mg Tab [FMC],2572006,CDM,250,RC,,,OUTPATIENT,1,EA,15.01,9.006,,12.76,85,,10.208,Percent of total billed charges,85% of total billed charges,7.51,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.51,50,,16,percent of total billed charges,50% of total billed charges,4.8,31.95,,19.48,percent of total billed charges,31.95% of total billed charges,4.8,31.95,,19.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,4.56,percent of total billed charges,38% of total billed charges,6,40,,24.384,percent of total billed charges,40% of total billed charges,4.8,12.76,
zolpidem 10 mg Tab [FMC],2572006,CDM,250,RC,,,OUTPATIENT,1,EA,15.03,9.018,,12.78,85,,10.224,Percent of total billed charges,85% of total billed charges,7.52,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.52,50,,8.8,percent of total billed charges,50% of total billed charges,4.8,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,4.8,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.71,38,,4.568,percent of total billed charges,38% of total billed charges,6.01,40,,3.064,percent of total billed charges,40% of total billed charges,4.8,12.78,
carvedilol 12.5 mg Tab [FMC],2572055,CDM,250,RC,,,OUTPATIENT,1,EA,6.94,4.164,,5.9,85,,4.72,Percent of total billed charges,85% of total billed charges,3.47,50,,150.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,8.4,percent of total billed charges,50% of total billed charges,2.22,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,2.22,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.64,38,,2.112,percent of total billed charges,38% of total billed charges,2.78,40,,3.064,percent of total billed charges,40% of total billed charges,2.22,5.9,
carvedilol 12.5 mg Tab [FMC],2572055,CDM,250,RC,,,OUTPATIENT,1,EA,6.34,3.804,,5.39,85,,4.312,Percent of total billed charges,85% of total billed charges,3.17,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.17,50,,599.152,percent of total billed charges,50% of total billed charges,2.03,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,2.03,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.41,38,,1.928,percent of total billed charges,38% of total billed charges,2.54,40,,3.064,percent of total billed charges,40% of total billed charges,2.03,5.39,
carvedilol 12.5 mg Tab [FMC],2572055,CDM,250,RC,,,OUTPATIENT,1,EA,6.83,4.098,,5.81,85,,4.648,Percent of total billed charges,85% of total billed charges,3.42,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.42,50,,28.8,percent of total billed charges,50% of total billed charges,2.18,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,2.18,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.6,38,,2.08,percent of total billed charges,38% of total billed charges,2.73,40,,3.064,percent of total billed charges,40% of total billed charges,2.18,5.81,
carvedilol 12.5 mg Tab [FMC],2572055,CDM,250,RC,,,OUTPATIENT,1,EA,6.94,4.164,,5.9,85,,4.72,Percent of total billed charges,85% of total billed charges,3.47,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.47,50,,116,percent of total billed charges,50% of total billed charges,2.22,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,2.22,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.64,38,,2.112,percent of total billed charges,38% of total billed charges,2.78,40,,3.064,percent of total billed charges,40% of total billed charges,2.22,5.9,
nitroglycerin 20 mg/100 mL-D5W IV Sol [FMC],2572063,CDM,250,RC,,,OUTPATIENT,250,ML,87.9,52.74,,74.72,85,,59.776,Percent of total billed charges,85% of total billed charges,43.95,50,,640,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,43.95,50,,480,percent of total billed charges,50% of total billed charges,28.08,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,28.08,31.95,,544.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.4,38,,26.72,percent of total billed charges,38% of total billed charges,35.16,40,,3.064,percent of total billed charges,40% of total billed charges,28.08,74.72,
enoxaparin 80 mg/0.8 mL SC Sol [FMC],2572071,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.8,ML,232.21,139.326,,197.38,85,,157.904,Percent of total billed charges,85% of total billed charges,1,136.6,,610,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1409.76,fee schedule,136.60% of BCBS custom fee schedule,81.62,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,74.19,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.24,38,,70.592,percent of total billed charges,38% of total billed charges,74.19,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,1,197.38,
enoxaparin 80 mg/0.8 mL SC Sol [FMC],2572071,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.8,ML,258.3,154.98,,219.56,85,,175.648,Percent of total billed charges,85% of total billed charges,1,136.6,,105.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,1000,fee schedule,136.60% of BCBS custom fee schedule,90.79,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,82.53,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,98.15,38,,78.52,percent of total billed charges,38% of total billed charges,82.53,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,1,219.56,
enoxaparin 80 mg/0.8 mL SC Sol [FMC],2572071,CDM,250,RC,J1650,HCPCS,OUTPATIENT,0.8,ML,72.65,43.59,,61.75,85,,49.4,Percent of total billed charges,85% of total billed charges,1,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1,136.6,,236,fee schedule,136.60% of BCBS custom fee schedule,25.54,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,23.21,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.61,38,,22.088,percent of total billed charges,38% of total billed charges,23.21,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,1,61.75,
ramelteon 8 mg oral tablet [FMC],2572105,CDM,250,RC,,,OUTPATIENT,1,EA,29.93,17.958,,25.44,85,,20.352,Percent of total billed charges,85% of total billed charges,14.97,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.97,50,,874,percent of total billed charges,50% of total billed charges,9.56,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,9.56,31.95,,562.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.37,38,,9.096,percent of total billed charges,38% of total billed charges,11.97,40,,3.064,percent of total billed charges,40% of total billed charges,9.56,25.44,
ramelteon 8 mg oral tablet [FMC],2572105,CDM,250,RC,,,OUTPATIENT,1,EA,45.47,27.282,,38.65,85,,30.92,Percent of total billed charges,85% of total billed charges,22.74,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.74,50,,1400,percent of total billed charges,50% of total billed charges,14.53,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,14.53,31.95,,576.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.28,38,,13.824,percent of total billed charges,38% of total billed charges,18.19,40,,3.064,percent of total billed charges,40% of total billed charges,14.53,38.65,
"sodium chloride, hypertonic, Ophth 5% Sol [FMC]",2572121,CDM,250,RC,,,OUTPATIENT,15,EA,34.97,20.982,,29.72,85,,23.776,Percent of total billed charges,85% of total billed charges,17.49,50,,47.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.49,50,,104,percent of total billed charges,50% of total billed charges,11.17,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,11.17,31.95,,576.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.29,38,,10.632,percent of total billed charges,38% of total billed charges,13.99,40,,3.064,percent of total billed charges,40% of total billed charges,11.17,29.72,
"sodium chloride, hypertonic, Ophth 5% Sol [FMC]",2572121,CDM,250,RC,,,OUTPATIENT,15,EA,47.94,28.764,,40.75,85,,32.6,Percent of total billed charges,85% of total billed charges,23.97,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.97,50,,655.2,percent of total billed charges,50% of total billed charges,15.32,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,15.32,31.95,,587.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.22,38,,14.576,percent of total billed charges,38% of total billed charges,19.18,40,,3.064,percent of total billed charges,40% of total billed charges,15.32,40.75,
"sodium chloride, hypertonic, Ophth 5% Sol [FMC]",2572121,CDM,250,RC,,,OUTPATIENT,15,EA,62.34,37.404,,52.99,85,,42.392,Percent of total billed charges,85% of total billed charges,31.17,50,,26.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.17,50,,67.2,percent of total billed charges,50% of total billed charges,19.92,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,19.92,31.95,,587.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.69,38,,18.952,percent of total billed charges,38% of total billed charges,24.94,40,,3.064,percent of total billed charges,40% of total billed charges,19.92,52.99,
morphine 15 mg ER Tab [FMC],2572162,CDM,250,RC,,,OUTPATIENT,1,EA,5.45,3.27,,4.63,85,,3.704,Percent of total billed charges,85% of total billed charges,2.73,50,,6.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.73,50,,140,percent of total billed charges,50% of total billed charges,1.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.07,38,,1.656,percent of total billed charges,38% of total billed charges,2.18,40,,0.96,percent of total billed charges,40% of total billed charges,1.74,4.63,
morphine 15 mg ER Tab [FMC],2572162,CDM,250,RC,,,OUTPATIENT,1,EA,5.45,3.27,,4.63,85,,3.704,Percent of total billed charges,85% of total billed charges,2.73,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.73,50,,159.6,percent of total billed charges,50% of total billed charges,1.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.07,38,,1.656,percent of total billed charges,38% of total billed charges,2.18,40,,0.96,percent of total billed charges,40% of total billed charges,1.74,4.63,
morphine 15 mg ER Tab [FMC],2572162,CDM,250,RC,,,OUTPATIENT,1,EA,5.99,3.594,,5.09,85,,4.072,Percent of total billed charges,85% of total billed charges,3,50,,68.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,318.8,percent of total billed charges,50% of total billed charges,1.91,31.95,,7.792,percent of total billed charges,31.95% of total billed charges,1.91,31.95,,7.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,9.76,percent of total billed charges,40% of total billed charges,1.91,5.09,
morphine 15 mg ER Tab [FMC],2572162,CDM,250,RC,,,OUTPATIENT,1,EA,4.46,2.676,,3.79,85,,3.032,Percent of total billed charges,85% of total billed charges,2.23,50,,18.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.23,50,,655.2,percent of total billed charges,50% of total billed charges,1.42,31.95,,8.568,percent of total billed charges,31.95% of total billed charges,1.42,31.95,,8.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.69,38,,1.352,percent of total billed charges,38% of total billed charges,1.78,40,,10.728,percent of total billed charges,40% of total billed charges,1.42,3.79,
morphine 15 mg ER Tab [FMC],2572162,CDM,250,RC,,,OUTPATIENT,1,EA,6.08,3.648,,5.17,85,,4.136,Percent of total billed charges,85% of total billed charges,3.04,50,,25.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.04,50,,128,percent of total billed charges,50% of total billed charges,1.94,31.95,,9.808,percent of total billed charges,31.95% of total billed charges,1.94,31.95,,9.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.31,38,,1.848,percent of total billed charges,38% of total billed charges,2.43,40,,12.272,percent of total billed charges,40% of total billed charges,1.94,5.17,
"fentaNYL 12 mcg/hr TD film, ER [FMC]",2572170,CDM,250,RC,,,OUTPATIENT,1,EA,65.98,39.588,,56.08,85,,44.864,Percent of total billed charges,85% of total billed charges,32.99,50,,53.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.99,50,,36,percent of total billed charges,50% of total billed charges,21.08,31.95,,12.512,percent of total billed charges,31.95% of total billed charges,21.08,31.95,,12.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.07,38,,20.056,percent of total billed charges,38% of total billed charges,26.39,40,,15.664,percent of total billed charges,40% of total billed charges,21.08,56.08,
"fentaNYL 12 mcg/hr TD film, ER [FMC]",2572170,CDM,250,RC,,,OUTPATIENT,1,EA,65.98,39.588,,56.08,85,,44.864,Percent of total billed charges,85% of total billed charges,32.99,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.99,50,,380,percent of total billed charges,50% of total billed charges,21.08,31.95,,12.512,percent of total billed charges,31.95% of total billed charges,21.08,31.95,,12.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.07,38,,20.056,percent of total billed charges,38% of total billed charges,26.39,40,,15.664,percent of total billed charges,40% of total billed charges,21.08,56.08,
"fentaNYL 12 mcg/hr TD film, ER [FMC]",2572170,CDM,250,RC,,,OUTPATIENT,1,EA,65.98,39.588,,56.08,85,,44.864,Percent of total billed charges,85% of total billed charges,32.99,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.99,50,,40,percent of total billed charges,50% of total billed charges,21.08,31.95,,269.328,percent of total billed charges,31.95% of total billed charges,21.08,31.95,,269.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.07,38,,20.056,percent of total billed charges,38% of total billed charges,26.39,40,,337.184,percent of total billed charges,40% of total billed charges,21.08,56.08,
"fentaNYL 12 mcg/hr TD film, ER [FMC]",2572170,CDM,250,RC,,,OUTPATIENT,1,EA,65.98,39.588,,56.08,85,,44.864,Percent of total billed charges,85% of total billed charges,32.99,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.99,50,,136,percent of total billed charges,50% of total billed charges,21.08,31.95,,6.368,percent of total billed charges,31.95% of total billed charges,21.08,31.95,,6.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.07,38,,20.056,percent of total billed charges,38% of total billed charges,26.39,40,,7.968,percent of total billed charges,40% of total billed charges,21.08,56.08,
"fentaNYL 12 mcg/hr TD film, ER [FMC]",2572170,CDM,250,RC,,,OUTPATIENT,1,EA,65.98,39.588,,56.08,85,,44.864,Percent of total billed charges,85% of total billed charges,32.99,50,,4.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.99,50,,280,percent of total billed charges,50% of total billed charges,21.08,31.95,,6.536,percent of total billed charges,31.95% of total billed charges,21.08,31.95,,6.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.07,38,,20.056,percent of total billed charges,38% of total billed charges,26.39,40,,8.176,percent of total billed charges,40% of total billed charges,21.08,56.08,
"fentaNYL 12 mcg/hr TD film, ER [FMC]",2572170,CDM,250,RC,,,OUTPATIENT,1,EA,65.98,39.588,,56.08,85,,44.864,Percent of total billed charges,85% of total billed charges,32.99,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.99,50,,28,percent of total billed charges,50% of total billed charges,21.08,31.95,,6.048,percent of total billed charges,31.95% of total billed charges,21.08,31.95,,6.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.07,38,,20.056,percent of total billed charges,38% of total billed charges,26.39,40,,7.576,percent of total billed charges,40% of total billed charges,21.08,56.08,
aluminum hydroxide-magnesium hydroxide 200 mg-200 mg/5 mL Oral Susp 30 mL [FMC],2572188,CDM,250,RC,,,OUTPATIENT,30,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,38,percent of total billed charges,50% of total billed charges,0.96,31.95,,8.24,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,8.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,10.32,percent of total billed charges,40% of total billed charges,0.96,2.55,
acetaZOLAMIDE 500 mg REC inj [FMC],2572238,CDM,250,RC,J1120,HCPCS,OUTPATIENT,1,EA,127.99,76.794,,108.79,85,,87.032,Percent of total billed charges,85% of total billed charges,39.55,136.6,,9.904,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.55,136.6,,50,fee schedule,136.60% of BCBS custom fee schedule,44.99,35.15,,3.128,percent of total billed charges,35.15% of total billed charges,54.18,31.95,,3.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.64,38,,38.912,percent of total billed charges,38% of total billed charges,40.89,31.95,,3.92,percent of total billed charges,31.95% of total billed charges,39.55,108.79,
cefepime 2 g Inj [FMC],2572287,CDM,250,RC,J0692,HCPCS,OUTPATIENT,1,EA,38.22,22.932,,32.49,85,,25.992,Percent of total billed charges,85% of total billed charges,1.91,136.6,,3.472,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.91,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,13.43,35.15,,61.216,fee schedule,35.15% of LA custom fee schedule,12.21,31.95,,61.216,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.52,38,,11.616,percent of total billed charges,38% of total billed charges,12.21,31.95,,76.64,Fee Schedule,31.95% of LA custom fee schedule,1.91,32.49,
cefepime 2 g Inj [FMC],2572287,CDM,250,RC,J0692,HCPCS,OUTPATIENT,1,EA,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,1.91,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.91,136.6,,30,fee schedule,136.60% of BCBS custom fee schedule,13.71,35.15,,58.152,fee schedule,35.15% of LA custom fee schedule,12.46,31.95,,58.152,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,12.46,31.95,,72.808,Fee Schedule,31.95% of LA custom fee schedule,1.91,33.15,
cefepime 2 g Inj [FMC],2572287,CDM,250,RC,J0692,HCPCS,OUTPATIENT,1,EA,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,1.91,136.6,,63.96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.91,136.6,,200.552,fee schedule,136.60% of BCBS custom fee schedule,13.71,35.15,,51.216,fee schedule,35.15% of LA custom fee schedule,12.46,31.95,,595.296,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,12.46,31.95,,46.552,Fee Schedule,31.95% of LA custom fee schedule,1.91,33.15,
cefepime 2 g Inj [FMC],2572287,CDM,250,RC,J0692,HCPCS,OUTPATIENT,1,EA,37.83,22.698,,32.16,85,,25.728,Percent of total billed charges,85% of total billed charges,1.91,136.6,,50,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.91,136.6,,75.2,fee schedule,136.60% of BCBS custom fee schedule,13.3,35.15,,3.424,fee schedule,35.15% of LA custom fee schedule,12.09,31.95,,642.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.38,38,,11.504,percent of total billed charges,38% of total billed charges,12.09,31.95,,3.112,Fee Schedule,31.95% of LA custom fee schedule,1.91,32.16,
chlorhexidine Top 4% Soap [FMC],2572303,CDM,250,RC,,,OUTPATIENT,237,EA,21.95,13.17,,18.66,85,,14.928,Percent of total billed charges,85% of total billed charges,10.98,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.98,50,,920,percent of total billed charges,50% of total billed charges,7.01,31.95,,8.656,percent of total billed charges,31.95% of total billed charges,7.01,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.34,38,,6.672,percent of total billed charges,38% of total billed charges,8.78,40,,7.864,percent of total billed charges,40% of total billed charges,7.01,18.66,
chlorhexidine Top 4% Soap [FMC],2572303,CDM,250,RC,,,OUTPATIENT,237,EA,26.17,15.702,,22.24,85,,17.792,Percent of total billed charges,85% of total billed charges,13.09,50,,48.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.09,50,,468,percent of total billed charges,50% of total billed charges,8.36,31.95,,8.656,percent of total billed charges,31.95% of total billed charges,8.36,31.95,,656.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.94,38,,7.952,percent of total billed charges,38% of total billed charges,10.47,40,,7.864,percent of total billed charges,40% of total billed charges,8.36,22.24,
chlorhexidine Top 4% Soap [FMC],2572303,CDM,250,RC,,,OUTPATIENT,237,EA,18.65,11.19,,15.85,85,,12.68,Percent of total billed charges,85% of total billed charges,9.33,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.33,50,,150,percent of total billed charges,50% of total billed charges,5.96,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,5.96,31.95,,669.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.09,38,,5.672,percent of total billed charges,38% of total billed charges,7.46,40,,9.296,percent of total billed charges,40% of total billed charges,5.96,15.85,
levofloxacin 500 mg Tab UD [FMC],2572360,CDM,250,RC,,,OUTPATIENT,1,EA,54.67,32.802,,46.47,85,,37.176,Percent of total billed charges,85% of total billed charges,27.34,50,,1.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.34,50,,30,percent of total billed charges,50% of total billed charges,17.47,31.95,,13.712,percent of total billed charges,31.95% of total billed charges,17.47,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.77,38,,16.616,percent of total billed charges,38% of total billed charges,21.87,40,,12.464,percent of total billed charges,40% of total billed charges,17.47,46.47,
levofloxacin 50mg tab {FMC},2572360,CDM,250,RC,,,OUTPATIENT,1,EA,61.43,36.858,,52.22,85,,41.776,Percent of total billed charges,85% of total billed charges,30.72,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.72,50,,30,percent of total billed charges,50% of total billed charges,19.63,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,19.63,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.34,38,,18.672,percent of total billed charges,38% of total billed charges,24.57,40,,3.064,percent of total billed charges,40% of total billed charges,19.63,52.22,
ampicillin 500 mg Inj [FMC],2572378,CDM,250,RC,J0290,HCPCS,OUTPATIENT,1,EA,13.6,8.16,,11.56,85,,9.248,Percent of total billed charges,85% of total billed charges,1.43,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.43,136.6,,30,fee schedule,136.60% of BCBS custom fee schedule,4.78,35.15,,41.864,fee schedule,35.15% of LA custom fee schedule,4.35,31.95,,41.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.17,38,,4.136,percent of total billed charges,38% of total billed charges,4.35,31.95,,52.416,Fee Schedule,31.95% of LA custom fee schedule,1.43,11.56,
carbidopa/entacapone/levodopa 12.5 mg-200 mg-50 mg Tab [FMC],2572444,CDM,250,RC,,,OUTPATIENT,1,EA,12.18,7.308,,10.35,85,,8.28,Percent of total billed charges,85% of total billed charges,6.09,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.09,50,,240,percent of total billed charges,50% of total billed charges,3.89,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,3.89,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.63,38,,3.704,percent of total billed charges,38% of total billed charges,4.87,40,,0.768,percent of total billed charges,40% of total billed charges,3.89,10.35,
carbidopa/entacapone/levodopa 12.5 mg-200 mg-50 mg Tab [FMC],2572444,CDM,250,RC,,,OUTPATIENT,1,EA,12.19,7.314,,10.36,85,,8.288,Percent of total billed charges,85% of total billed charges,6.1,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.1,50,,240,percent of total billed charges,50% of total billed charges,3.89,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,3.89,31.95,,718.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.63,38,,3.704,percent of total billed charges,38% of total billed charges,4.88,40,,0.768,percent of total billed charges,40% of total billed charges,3.89,10.36,
carbidopa/entacapone/levodopa 12.5 mg-200 mg-50 mg Tab [FMC],2572444,CDM,250,RC,,,OUTPATIENT,1,EA,12.19,7.314,,10.36,85,,8.288,Percent of total billed charges,85% of total billed charges,6.1,50,,50.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.1,50,,30,percent of total billed charges,50% of total billed charges,3.89,31.95,,2.064,percent of total billed charges,31.95% of total billed charges,3.89,31.95,,2.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.63,38,,3.704,percent of total billed charges,38% of total billed charges,4.88,40,,2.592,percent of total billed charges,40% of total billed charges,3.89,10.36,
terbinafine Top 1% Crm [FMC],2572469,CDM,250,RC,,,OUTPATIENT,15,EA,34.86,20.916,,29.63,85,,23.704,Percent of total billed charges,85% of total billed charges,17.43,50,,229.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.43,50,,140.8,percent of total billed charges,50% of total billed charges,11.14,31.95,,2.176,percent of total billed charges,31.95% of total billed charges,11.14,31.95,,2.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.25,38,,10.6,percent of total billed charges,38% of total billed charges,13.94,40,,2.72,percent of total billed charges,40% of total billed charges,11.14,29.63,
terbinafine Top 1% Crm [FMC],2572469,CDM,250,RC,,,OUTPATIENT,15,EA,34.86,20.916,,29.63,85,,23.704,Percent of total billed charges,85% of total billed charges,17.43,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.43,50,,140.8,percent of total billed charges,50% of total billed charges,11.14,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,11.14,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.25,38,,10.6,percent of total billed charges,38% of total billed charges,13.94,40,,1.92,percent of total billed charges,40% of total billed charges,11.14,29.63,
terbinafine Top 1% Crm [FMC],2572469,CDM,250,RC,,,OUTPATIENT,15,EA,43.84,26.304,,37.26,85,,29.808,Percent of total billed charges,85% of total billed charges,21.92,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.92,50,,221.6,percent of total billed charges,50% of total billed charges,14.01,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,14.01,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.66,38,,13.328,percent of total billed charges,38% of total billed charges,17.54,40,,1.92,percent of total billed charges,40% of total billed charges,14.01,37.26,
#NAME?,2572501,CDM,250,RC,,,OUTPATIENT,1,EA,24.12,14.472,,20.5,85,,16.4,Percent of total billed charges,85% of total billed charges,12.06,50,,15.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.06,50,,221.6,percent of total billed charges,50% of total billed charges,7.71,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,7.71,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.17,38,,7.336,percent of total billed charges,38% of total billed charges,9.65,40,,1.92,percent of total billed charges,40% of total billed charges,7.71,20.5,
lubiprostone 24 mcg Cap-  - Inpatient - FMC HOSP - Active - 64764-0240-60 -  - Inpatient - FMC HOSP - Active - 64764-0240-6-  - Inpatient - FMC HOSP -,2572501,CDM,250,RC,,,OUTPATIENT,1,EA,21.71,13.026,,18.45,85,,14.76,Percent of total billed charges,85% of total billed charges,10.86,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.86,50,,221.6,percent of total billed charges,50% of total billed charges,6.94,31.95,,2.952,percent of total billed charges,31.95% of total billed charges,6.94,31.95,,2.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.25,38,,6.6,percent of total billed charges,38% of total billed charges,8.68,40,,3.696,percent of total billed charges,40% of total billed charges,6.94,18.45,
linezolid inj 600mg/300ml [FMC],2572543,CDM,250,RC,J2020,HCPCS,OUTPATIENT,300,ML,312,187.2,,265.2,85,,212.16,Percent of total billed charges,85% of total billed charges,5.49,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.49,136.6,,160.4,fee schedule,136.60% of BCBS custom fee schedule,109.67,35.15,,9.264,fee schedule,35.15% of LA custom fee schedule,99.68,31.95,,718.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,118.56,38,,94.848,percent of total billed charges,38% of total billed charges,99.68,31.95,,8.424,Fee Schedule,31.95% of LA custom fee schedule,5.49,265.2,
linezolid inj 600mg/300ml [FMC],2572543,CDM,250,RC,J2020,HCPCS,OUTPATIENT,300,ML,187.52,112.512,,159.39,85,,127.512,Percent of total billed charges,85% of total billed charges,5.49,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.49,136.6,,160.4,fee schedule,136.60% of BCBS custom fee schedule,65.91,35.15,,10.312,fee schedule,35.15% of LA custom fee schedule,59.91,31.95,,730.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,71.26,38,,57.008,percent of total billed charges,38% of total billed charges,59.91,31.95,,9.376,Fee Schedule,31.95% of LA custom fee schedule,5.49,159.39,
"Penicillin G Potassium 5,000,000 units REC [FMC]",2572568,CDM,250,RC,J2540,HCPCS,OUTPATIENT,1,EA,49.61,29.766,,42.17,85,,33.736,Percent of total billed charges,85% of total billed charges,1.23,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.23,136.6,,160.4,fee schedule,136.60% of BCBS custom fee schedule,17.44,35.15,,10.312,fee schedule,35.15% of LA custom fee schedule,15.85,31.95,,730.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.85,38,,15.08,percent of total billed charges,38% of total billed charges,15.85,31.95,,9.376,Fee Schedule,31.95% of LA custom fee schedule,1.23,42.17,
simvastatin 40 mg Tab [FMC],2572584,CDM,250,RC,,,OUTPATIENT,1,EA,15.99,9.594,,13.59,85,,10.872,Percent of total billed charges,85% of total billed charges,8,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,210,percent of total billed charges,50% of total billed charges,5.11,31.95,,19.744,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,756.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,6.4,40,,17.944,percent of total billed charges,40% of total billed charges,5.11,13.59,
simvastatin 40 mg Tab [FMC],2572584,CDM,250,RC,,,OUTPATIENT,1,EA,14.31,8.586,,12.16,85,,9.728,Percent of total billed charges,85% of total billed charges,7.16,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.16,50,,210,percent of total billed charges,50% of total billed charges,4.57,31.95,,21.152,percent of total billed charges,31.95% of total billed charges,4.57,31.95,,761.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.44,38,,4.352,percent of total billed charges,38% of total billed charges,5.72,40,,19.224,percent of total billed charges,40% of total billed charges,4.57,12.16,
simvastatin 40 mg Tab [FMC],2572584,CDM,250,RC,,,OUTPATIENT,1,EA,15.99,9.594,,13.59,85,,10.872,Percent of total billed charges,85% of total billed charges,8,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,210,percent of total billed charges,50% of total billed charges,5.11,31.95,,27.624,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,27.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,6.4,40,,34.584,percent of total billed charges,40% of total billed charges,5.11,13.59,
simvastatin 40 mg Tab [FMC],2572584,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,69.04,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
losartan 25 mg Tab [FMC],2572618,CDM,250,RC,,,OUTPATIENT,1,EA,5.55,3.33,,4.72,85,,3.776,Percent of total billed charges,85% of total billed charges,2.78,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.78,50,,69.04,percent of total billed charges,50% of total billed charges,1.77,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.77,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.11,38,,1.688,percent of total billed charges,38% of total billed charges,2.22,40,,9.2,percent of total billed charges,40% of total billed charges,1.77,4.72,
losartan 25 mg Tab [FMC],2572618,CDM,250,RC,,,OUTPATIENT,1,EA,5.45,3.27,,4.63,85,,3.704,Percent of total billed charges,85% of total billed charges,2.73,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.73,50,,69.04,percent of total billed charges,50% of total billed charges,1.74,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,1.74,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.07,38,,1.656,percent of total billed charges,38% of total billed charges,2.18,40,,9.2,percent of total billed charges,40% of total billed charges,1.74,4.63,
losartan 25 mg Tab [FMC],2572618,CDM,250,RC,,,OUTPATIENT,1,EA,5.47,3.282,,4.65,85,,3.72,Percent of total billed charges,85% of total billed charges,2.74,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.74,50,,236,percent of total billed charges,50% of total billed charges,1.75,31.95,,53.248,percent of total billed charges,31.95% of total billed charges,1.75,31.95,,53.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.08,38,,1.664,percent of total billed charges,38% of total billed charges,2.19,40,,66.664,percent of total billed charges,40% of total billed charges,1.75,4.65,
losartan 25 mg Tab [FMC],2572618,CDM,250,RC,,,OUTPATIENT,1,EA,10.8,6.48,,9.18,85,,7.344,Percent of total billed charges,85% of total billed charges,5.4,50,,59.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.4,50,,42.4,percent of total billed charges,50% of total billed charges,3.45,31.95,,55.648,percent of total billed charges,31.95% of total billed charges,3.45,31.95,,55.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.1,38,,3.28,percent of total billed charges,38% of total billed charges,4.32,40,,69.664,percent of total billed charges,40% of total billed charges,3.45,9.18,
losartan 25 mg Tab [FMC],2572618,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,47.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,90,percent of total billed charges,50% of total billed charges,0.96,31.95,,55.648,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,55.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,69.664,percent of total billed charges,40% of total billed charges,0.96,2.55,
losartan 25 mg Tab [FMC],2572618,CDM,250,RC,,,OUTPATIENT,1,EA,11.33,6.798,,9.63,85,,7.704,Percent of total billed charges,85% of total billed charges,5.67,50,,15.032,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.67,50,,230,percent of total billed charges,50% of total billed charges,3.62,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,3.62,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.31,38,,3.448,percent of total billed charges,38% of total billed charges,4.53,40,,1.28,percent of total billed charges,40% of total billed charges,3.62,9.63,
losartan 25 mg Tab [FMC],2572618,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,230,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
"EPINEPHrine-lidocaine 1:100,000-2% Inj Sol 20 mL [FMC]",2572659,CDM,250,RC,,,OUTPATIENT,20,ML,14.82,8.892,,12.6,85,,10.08,Percent of total billed charges,85% of total billed charges,7.41,50,,4.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.41,50,,318.8,percent of total billed charges,50% of total billed charges,4.73,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,4.73,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.63,38,,4.504,percent of total billed charges,38% of total billed charges,5.93,40,,1.28,percent of total billed charges,40% of total billed charges,4.73,12.6,
"EPINEPHrine-lidocaine 1:100,000-2% Inj Sol 20 mL [FMC]",2572659,CDM,250,RC,,,OUTPATIENT,20,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,476,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,318.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,1.28,percent of total billed charges,40% of total billed charges,3.83,10.2,
naloxone 1 mg/mL Inj Sol [FMC],2572667,CDM,250,RC,J2310,HCPCS,OUTPATIENT,2,ML,128.7,77.22,,109.4,85,,87.52,Percent of total billed charges,85% of total billed charges,14.33,136.6,,740,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.33,136.6,,318.8,fee schedule,136.60% of BCBS custom fee schedule,45.24,35.15,,141.096,fee schedule,35.15% of LA custom fee schedule,41.12,31.95,,51.632,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,48.91,38,,39.128,percent of total billed charges,38% of total billed charges,41.12,31.95,,128.256,Fee Schedule,31.95% of LA custom fee schedule,14.33,109.4,
vitamin E  450 mg Oral Cap [FMC],2572675,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,318.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,128.384,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,52.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,116.696,percent of total billed charges,40% of total billed charges,0.96,2.55,
camphor-menthol topical 1.7%-0.7% Oin [FMC],2572709,CDM,250,RC,,,OUTPATIENT,7.5,EA,23.4,14.04,,19.89,85,,15.912,Percent of total billed charges,85% of total billed charges,11.7,50,,133.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.7,50,,318.4,percent of total billed charges,50% of total billed charges,7.48,31.95,,81.456,percent of total billed charges,31.95% of total billed charges,7.48,31.95,,52.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,9.36,40,,74.04,percent of total billed charges,40% of total billed charges,7.48,19.89,
ranolazine 500 mg ER [FMC],2572717,CDM,250,RC,,,OUTPATIENT,1,EA,26.72,16.032,,22.71,85,,18.168,Percent of total billed charges,85% of total billed charges,13.36,50,,644,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.36,50,,318.4,percent of total billed charges,50% of total billed charges,8.54,31.95,,87.736,percent of total billed charges,31.95% of total billed charges,8.54,31.95,,53.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.15,38,,8.12,percent of total billed charges,38% of total billed charges,10.69,40,,79.744,percent of total billed charges,40% of total billed charges,8.54,22.71,
ranolazine 500 mg ER [FMC],2572717,CDM,250,RC,,,OUTPATIENT,1,EA,15.96,9.576,,13.57,85,,10.856,Percent of total billed charges,85% of total billed charges,7.98,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.98,50,,318.8,percent of total billed charges,50% of total billed charges,5.1,31.95,,109.672,percent of total billed charges,31.95% of total billed charges,5.1,31.95,,56.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.06,38,,4.848,percent of total billed charges,38% of total billed charges,6.38,40,,99.688,percent of total billed charges,40% of total billed charges,5.1,13.57,
ranolazine 500 mg ER [FMC],2572717,CDM,250,RC,,,OUTPATIENT,1,EA,23.12,13.872,,19.65,85,,15.72,Percent of total billed charges,85% of total billed charges,11.56,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.56,50,,318.8,percent of total billed charges,50% of total billed charges,7.39,31.95,,128.384,percent of total billed charges,31.95% of total billed charges,7.39,31.95,,56.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.79,38,,7.032,percent of total billed charges,38% of total billed charges,9.25,40,,116.696,percent of total billed charges,40% of total billed charges,7.39,19.65,
ranolazine 500 mg ER [FMC],2572717,CDM,250,RC,,,OUTPATIENT,1,EA,5.46,3.276,,4.64,85,,3.712,Percent of total billed charges,85% of total billed charges,2.73,50,,5.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.73,50,,655.2,percent of total billed charges,50% of total billed charges,1.74,31.95,,10.68,percent of total billed charges,31.95% of total billed charges,1.74,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.07,38,,1.656,percent of total billed charges,38% of total billed charges,2.18,40,,9.712,percent of total billed charges,40% of total billed charges,1.74,4.64,
propranolol 40 mg Tab [FMC],2572766,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,655.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,60.024,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 40 mg Tab [FMC],2572766,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,655.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,60.024,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 40 mg Tab [FMC],2572766,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,38.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,655.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,60.024,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 40 mg Tab [FMC],2572766,CDM,250,RC,,,OUTPATIENT,1,EA,4.24,2.544,,3.6,85,,2.88,Percent of total billed charges,85% of total billed charges,2.12,50,,6.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.12,50,,255.6,percent of total billed charges,50% of total billed charges,1.35,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,1.35,31.95,,47.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.61,38,,1.288,percent of total billed charges,38% of total billed charges,1.7,40,,60.024,percent of total billed charges,40% of total billed charges,1.35,3.6,
propranolol 40 mg Tab,2572766,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,655.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.632,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.664,percent of total billed charges,40% of total billed charges,0.96,2.55,
quiNINE 324 mg Cap [FMC],2572816,CDM,250,RC,,,OUTPATIENT,1,EA,23.81,14.286,,20.24,85,,16.192,Percent of total billed charges,85% of total billed charges,11.91,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.91,50,,655.2,percent of total billed charges,50% of total billed charges,7.61,31.95,,7.192,percent of total billed charges,31.95% of total billed charges,7.61,31.95,,7.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.05,38,,7.24,percent of total billed charges,38% of total billed charges,9.52,40,,9.008,percent of total billed charges,40% of total billed charges,7.61,20.24,
quiNINE 324 mg Cap [FMC],2572816,CDM,250,RC,,,OUTPATIENT,1,EA,23.92,14.352,,20.33,85,,16.264,Percent of total billed charges,85% of total billed charges,11.96,50,,23.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.96,50,,223.6,percent of total billed charges,50% of total billed charges,7.64,31.95,,11.256,percent of total billed charges,31.95% of total billed charges,7.64,31.95,,11.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.09,38,,7.272,percent of total billed charges,38% of total billed charges,9.57,40,,14.096,percent of total billed charges,40% of total billed charges,7.64,20.33,
quiNINE 324 mg Cap [FMC],2572816,CDM,250,RC,,,OUTPATIENT,1,EA,17.21,10.326,,14.63,85,,11.704,Percent of total billed charges,85% of total billed charges,8.61,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.61,50,,261.6,percent of total billed charges,50% of total billed charges,5.5,31.95,,14.472,percent of total billed charges,31.95% of total billed charges,5.5,31.95,,14.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.54,38,,5.232,percent of total billed charges,38% of total billed charges,6.88,40,,18.12,percent of total billed charges,40% of total billed charges,5.5,14.63,
procainamide 100 mg/mL Sol 10 mL [FMC],2572857,CDM,250,RC,J2690,HCPCS,OUTPATIENT,10,ML,129.08,77.448,,109.72,85,,87.776,Percent of total billed charges,85% of total billed charges,511.54,136.6,,48.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,511.54,136.6,,261.6,fee schedule,136.60% of BCBS custom fee schedule,45.37,35.15,,11.168,percent of total billed charges,35.15% of total billed charges,54.18,31.95,,11.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.05,38,,39.24,percent of total billed charges,38% of total billed charges,41.24,31.95,,13.976,percent of total billed charges,31.95% of total billed charges,41.24,511.54,
bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 mg-3.5 mg-10000 units per gm Oint [FMC],2572972,CDM,250,RC,,,OUTPATIENT,3.5,EA,211.41,126.846,,179.7,85,,143.76,Percent of total billed charges,85% of total billed charges,105.71,50,,158.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.71,50,,318.4,percent of total billed charges,50% of total billed charges,67.55,31.95,,9.992,percent of total billed charges,31.95% of total billed charges,67.55,31.95,,9.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80.34,38,,64.272,percent of total billed charges,38% of total billed charges,84.56,40,,12.504,percent of total billed charges,40% of total billed charges,67.55,179.7,
nebivolol 5 mg Tab UD [FMC],2573020,CDM,250,RC,,,OUTPATIENT,1,EA,11.31,6.786,,9.61,85,,7.688,Percent of total billed charges,85% of total billed charges,5.66,50,,153.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.66,50,,135.6,percent of total billed charges,50% of total billed charges,3.61,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,3.61,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.3,38,,3.44,percent of total billed charges,38% of total billed charges,4.52,40,,0.992,percent of total billed charges,40% of total billed charges,3.61,9.61,
nebivolol 5 mg Tab UD [FMC],2573020,CDM,250,RC,,,OUTPATIENT,1,EA,21.56,12.936,,18.33,85,,14.664,Percent of total billed charges,85% of total billed charges,10.78,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.78,50,,655.2,percent of total billed charges,50% of total billed charges,6.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,6.89,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.19,38,,6.552,percent of total billed charges,38% of total billed charges,8.62,40,,0.96,percent of total billed charges,40% of total billed charges,6.89,18.33,
nebivolol 5 mg Tab UD [FMC],2573020,CDM,250,RC,,,OUTPATIENT,1,EA,10.92,6.552,,9.28,85,,7.424,Percent of total billed charges,85% of total billed charges,5.46,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.46,50,,92.8,percent of total billed charges,50% of total billed charges,3.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.15,38,,3.32,percent of total billed charges,38% of total billed charges,4.37,40,,0.96,percent of total billed charges,40% of total billed charges,3.49,9.28,
nebivolol 5 mg Tab UD [FMC],2573020,CDM,250,RC,,,OUTPATIENT,1,EA,15.4,9.24,,13.09,85,,10.472,Percent of total billed charges,85% of total billed charges,7.7,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.7,50,,92.8,percent of total billed charges,50% of total billed charges,4.92,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,4.92,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.85,38,,4.68,percent of total billed charges,38% of total billed charges,6.16,40,,1.152,percent of total billed charges,40% of total billed charges,4.92,13.09,
potassium chloride 10 mEq/50 mL IV Sol [FMC],2573095,CDM,250,RC,J3480,HCPCS,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,51.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,92.8,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,13.168,percent of total billed charges,35.15% of total billed charges,54.18,31.95,,13.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,16.48,percent of total billed charges,31.95% of total billed charges,0.16,54.18,
potassium chloride 10 mEq/50 mL IV Sol [FMC],2573095,CDM,250,RC,J3480,HCPCS,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,69.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,67.2,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,12.44,percent of total billed charges,35.15% of total billed charges,54.59,31.95,,12.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,15.576,percent of total billed charges,31.95% of total billed charges,0.16,54.59,
potassium chloride 10 mEq/50 mL IV Sol [FMC],2573095,CDM,250,RC,J3480,HCPCS,OUTPATIENT,50,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,55.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,160,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,55.4,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.16,55.4,
potassium chloride 10 mEq/50 mL Solpotassium chloride 10 mEq/50 mL IV Sol [FMC],2573095,CDM,250,RC,J3480,HCPCS,OUTPATIENT,50,ML,234,140.4,,198.9,85,,159.12,Percent of total billed charges,85% of total billed charges,0.16,136.6,,56.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,67.2,fee schedule,136.60% of BCBS custom fee schedule,82.25,35.15,,12.28,percent of total billed charges,35.15% of total billed charges,55.59,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.92,38,,71.136,percent of total billed charges,38% of total billed charges,74.76,31.95,,11.168,percent of total billed charges,31.95% of total billed charges,0.16,198.9,
Dextrose 5% with NS and KCl 40 mEq/l IV Sol 1000 mL [FMC],2573103,CDM,250,RC,,,OUTPATIENT,1000,ML,54.57,32.742,,46.38,85,,37.104,Percent of total billed charges,85% of total billed charges,27.29,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.29,50,,120,percent of total billed charges,50% of total billed charges,17.44,31.95,,5.576,percent of total billed charges,31.95% of total billed charges,17.44,31.95,,59.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.74,38,,16.592,percent of total billed charges,38% of total billed charges,21.83,40,,5.072,percent of total billed charges,40% of total billed charges,17.44,46.38,
Dextrose 5% with NS and KCl 40 mEq/l IV Sol 1000 mL [FMC],2573103,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,62,percent of total billed charges,50% of total billed charges,11.5,31.95,,3.776,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,61.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,3.432,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% with NS and KCl 40 mEq/l IV Sol 1000 mL [FMC],2573103,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,140,percent of total billed charges,50% of total billed charges,11.5,31.95,,2.056,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,2.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,2.576,percent of total billed charges,40% of total billed charges,11.5,30.6,
pioglitazone 30 mg Tab [FMC],2573111,CDM,250,RC,,,OUTPATIENT,1,EA,34.8,20.88,,29.58,85,,23.664,Percent of total billed charges,85% of total billed charges,17.4,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.4,50,,256.8,percent of total billed charges,50% of total billed charges,11.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.22,38,,10.576,percent of total billed charges,38% of total billed charges,13.92,40,,0.96,percent of total billed charges,40% of total billed charges,11.12,29.58,
pioglitazone 30 mg Tab [FMC],2573111,CDM,250,RC,,,OUTPATIENT,1,EA,34.8,20.88,,29.58,85,,23.664,Percent of total billed charges,85% of total billed charges,17.4,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.4,50,,256.8,percent of total billed charges,50% of total billed charges,11.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,11.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.22,38,,10.576,percent of total billed charges,38% of total billed charges,13.92,40,,0.96,percent of total billed charges,40% of total billed charges,11.12,29.58,
pioglitazone 30 mg Tab [FMC],2573111,CDM,250,RC,,,OUTPATIENT,1,EA,34.8,20.88,,29.58,85,,23.664,Percent of total billed charges,85% of total billed charges,17.4,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.4,50,,84,percent of total billed charges,50% of total billed charges,11.12,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,11.12,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.22,38,,10.576,percent of total billed charges,38% of total billed charges,13.92,40,,1.28,percent of total billed charges,40% of total billed charges,11.12,29.58,
brimonidine-timolol Ophth 0.2%-0.5% Soln 5 mL [FMC],2573129,CDM,250,RC,,,OUTPATIENT,5,EA,403,241.8,,342.55,85,,274.04,Percent of total billed charges,85% of total billed charges,201.5,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,201.5,50,,170,percent of total billed charges,50% of total billed charges,128.76,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,128.76,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,153.14,38,,122.512,percent of total billed charges,38% of total billed charges,161.2,40,,1.28,percent of total billed charges,40% of total billed charges,128.76,342.55,
pantoprazole 40 mg oral Gran [FMC],2573160,CDM,250,RC,,,OUTPATIENT,1,EA,28.76,17.256,,24.45,85,,19.56,Percent of total billed charges,85% of total billed charges,14.38,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.38,50,,92.8,percent of total billed charges,50% of total billed charges,9.19,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,9.19,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.93,38,,8.744,percent of total billed charges,38% of total billed charges,11.5,40,,1.28,percent of total billed charges,40% of total billed charges,9.19,24.45,
pantoprazole 40 mg oral Gran [FMC],2573160,CDM,250,RC,,,OUTPATIENT,1,EA,55.21,33.126,,46.93,85,,37.544,Percent of total billed charges,85% of total billed charges,27.61,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.61,50,,92.8,percent of total billed charges,50% of total billed charges,17.64,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,17.64,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.98,38,,16.784,percent of total billed charges,38% of total billed charges,22.08,40,,1.28,percent of total billed charges,40% of total billed charges,17.64,46.93,
Sodium Chloride 0.9% with KCl 40 mEq/l IV Sol 1000 mL [FMC],2573186,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,92.8,percent of total billed charges,50% of total billed charges,11.5,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,1.28,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% with KCl 40 mEq/l IV Sol 1000 mL [FMC],2573186,CDM,250,RC,,,OUTPATIENT,1000,ML,42.87,25.722,,36.44,85,,29.152,Percent of total billed charges,85% of total billed charges,21.44,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.44,50,,92.8,percent of total billed charges,50% of total billed charges,13.7,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,13.7,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.29,38,,13.032,percent of total billed charges,38% of total billed charges,17.15,40,,1.28,percent of total billed charges,40% of total billed charges,13.7,36.44,
Sodium Chloride 0.9% with KCl 40 mEq/l IV Sol 1000 mL [FMC],2573186,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,92.8,percent of total billed charges,50% of total billed charges,11.5,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,1.28,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% with KCl 40 mEq/l IV Sol 1000 mL [FMC],2573186,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,92.8,percent of total billed charges,50% of total billed charges,11.5,31.95,,105.248,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,105.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,131.768,percent of total billed charges,40% of total billed charges,11.5,30.6,
aliskiren 150 mg Tab [FMC],2573194,CDM,250,RC,,,OUTPATIENT,1,EA,17.75,10.65,,15.09,85,,12.072,Percent of total billed charges,85% of total billed charges,8.88,50,,1320,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.88,50,,92.8,percent of total billed charges,50% of total billed charges,5.67,31.95,,91.52,percent of total billed charges,31.95% of total billed charges,5.67,31.95,,91.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.75,38,,5.4,percent of total billed charges,38% of total billed charges,7.1,40,,114.576,percent of total billed charges,40% of total billed charges,5.67,15.09,
aliskiren 150 mg Tab [FMC],2573194,CDM,250,RC,,,OUTPATIENT,1,EA,23.39,14.034,,19.88,85,,15.904,Percent of total billed charges,85% of total billed charges,11.7,50,,56.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.7,50,,92.8,percent of total billed charges,50% of total billed charges,7.47,31.95,,5.32,percent of total billed charges,31.95% of total billed charges,7.47,31.95,,5.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.89,38,,7.112,percent of total billed charges,38% of total billed charges,9.36,40,,6.656,percent of total billed charges,40% of total billed charges,7.47,19.88,
aliskiren 150 mg Tab [FMC],2573194,CDM,250,RC,,,OUTPATIENT,1,EA,24.31,14.586,,20.66,85,,16.528,Percent of total billed charges,85% of total billed charges,12.16,50,,31.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.16,50,,92.8,percent of total billed charges,50% of total billed charges,7.77,31.95,,6.8,percent of total billed charges,31.95% of total billed charges,7.77,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.24,38,,7.392,percent of total billed charges,38% of total billed charges,9.72,40,,6.176,percent of total billed charges,40% of total billed charges,7.77,20.66,
aliskiren 150 mg Tab [FMC],2573194,CDM,250,RC,,,OUTPATIENT,1,EA,25.39,15.234,,21.58,85,,17.264,Percent of total billed charges,85% of total billed charges,12.7,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.7,50,,84,percent of total billed charges,50% of total billed charges,8.11,31.95,,16.088,percent of total billed charges,31.95% of total billed charges,8.11,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.65,38,,7.72,percent of total billed charges,38% of total billed charges,10.16,40,,14.624,percent of total billed charges,40% of total billed charges,8.11,21.58,
methylene blue 10 mg/mL Sol [FMC],2573210,CDM,250,RC,,,OUTPATIENT,10,ML,670.39,402.234,,569.83,85,,455.864,Percent of total billed charges,85% of total billed charges,335.2,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,335.2,50,,84,percent of total billed charges,50% of total billed charges,214.19,31.95,,25.176,percent of total billed charges,31.95% of total billed charges,214.19,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,254.75,38,,203.8,percent of total billed charges,38% of total billed charges,268.16,40,,22.888,percent of total billed charges,40% of total billed charges,214.19,569.83,
methylene blue 10 mg/mL Sol [FMC],2573210,CDM,250,RC,,,OUTPATIENT,10,ML,819,491.4,,696.15,85,,556.92,Percent of total billed charges,85% of total billed charges,409.5,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,409.5,50,,84,percent of total billed charges,50% of total billed charges,261.67,31.95,,17.112,percent of total billed charges,31.95% of total billed charges,261.67,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,311.22,38,,248.976,percent of total billed charges,38% of total billed charges,327.6,40,,15.552,percent of total billed charges,40% of total billed charges,261.67,696.15,
memantine 10 mg Tab UD [FMC],2573228,CDM,250,RC,,,OUTPATIENT,1,EA,22.04,13.224,,18.73,85,,14.984,Percent of total billed charges,85% of total billed charges,11.02,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.02,50,,92.8,percent of total billed charges,50% of total billed charges,7.04,31.95,,19.256,percent of total billed charges,31.95% of total billed charges,7.04,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.38,38,,6.704,percent of total billed charges,38% of total billed charges,8.82,40,,17.504,percent of total billed charges,40% of total billed charges,7.04,18.73,
memantine 10 mg Tab [FMC],2573228,CDM,250,RC,,,OUTPATIENT,1,EA,3.1,1.86,,2.64,85,,2.112,Percent of total billed charges,85% of total billed charges,1.55,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.55,50,,92.8,percent of total billed charges,50% of total billed charges,0.99,31.95,,9.184,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.18,38,,0.944,percent of total billed charges,38% of total billed charges,1.24,40,,8.344,percent of total billed charges,40% of total billed charges,0.99,2.64,
memantine 10 mg Tab UD [FMC],2573228,CDM,250,RC,,,OUTPATIENT,1,EA,19.83,11.898,,16.86,85,,13.488,Percent of total billed charges,85% of total billed charges,9.92,50,,936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.92,50,,92.8,percent of total billed charges,50% of total billed charges,6.34,31.95,,25.176,percent of total billed charges,31.95% of total billed charges,6.34,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.54,38,,6.032,percent of total billed charges,38% of total billed charges,7.93,40,,22.888,percent of total billed charges,40% of total billed charges,6.34,16.86,
"rivastigmine 4.6 mg/24 hr TD film, ER [FMC]",2573277,CDM,250,RC,,,OUTPATIENT,1,EA,89.18,53.508,,75.8,85,,60.64,Percent of total billed charges,85% of total billed charges,44.59,50,,1120,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.59,50,,92.8,percent of total billed charges,50% of total billed charges,28.49,31.95,,19.88,percent of total billed charges,31.95% of total billed charges,28.49,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.89,38,,27.112,percent of total billed charges,38% of total billed charges,35.67,40,,18.072,percent of total billed charges,40% of total billed charges,28.49,75.8,
"rivastigmine 4.6 mg/24 hr TD film, ER [FMC]",2573277,CDM,250,RC,,,OUTPATIENT,1,EA,50.69,30.414,,43.09,85,,34.472,Percent of total billed charges,85% of total billed charges,25.35,50,,853.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.35,50,,294,percent of total billed charges,50% of total billed charges,16.2,31.95,,8.792,percent of total billed charges,31.95% of total billed charges,16.2,31.95,,8.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.26,38,,15.408,percent of total billed charges,38% of total billed charges,20.28,40,,11.008,percent of total billed charges,40% of total billed charges,16.2,43.09,
"rivastigmine 4.6 mg/24 hr TD film, ER [FMC]",2573277,CDM,250,RC,,,OUTPATIENT,1,EA,52.66,31.596,,44.76,85,,35.808,Percent of total billed charges,85% of total billed charges,26.33,50,,96.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.33,50,,200,percent of total billed charges,50% of total billed charges,16.82,31.95,,6.96,percent of total billed charges,31.95% of total billed charges,16.82,31.95,,6.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.01,38,,16.008,percent of total billed charges,38% of total billed charges,21.06,40,,8.72,percent of total billed charges,40% of total billed charges,16.82,44.76,
"rivastigmine 4.6 mg/24 hr TD film, ER [FMC]",2573277,CDM,250,RC,,,OUTPATIENT,1,EA,54.91,32.946,,46.67,85,,37.336,Percent of total billed charges,85% of total billed charges,27.46,50,,3.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.46,50,,160,percent of total billed charges,50% of total billed charges,17.54,31.95,,610.192,percent of total billed charges,31.95% of total billed charges,17.54,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.87,38,,16.696,percent of total billed charges,38% of total billed charges,21.96,40,,554.64,percent of total billed charges,40% of total billed charges,17.54,46.67,
niacin 500 mg ER Tab [FMC],2573343,CDM,250,RC,,,OUTPATIENT,1,EA,13.77,8.262,,11.7,85,,9.36,Percent of total billed charges,85% of total billed charges,6.89,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.89,50,,120,percent of total billed charges,50% of total billed charges,4.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.4,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.23,38,,4.184,percent of total billed charges,38% of total billed charges,5.51,40,,0.96,percent of total billed charges,40% of total billed charges,4.4,11.7,
niacin 500 mg ER Tab [FMC],2573343,CDM,250,RC,,,OUTPATIENT,1,EA,18.64,11.184,,15.84,85,,12.672,Percent of total billed charges,85% of total billed charges,9.32,50,,3.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.32,50,,1184,percent of total billed charges,50% of total billed charges,5.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,5.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.08,38,,5.664,percent of total billed charges,38% of total billed charges,7.46,40,,0.96,percent of total billed charges,40% of total billed charges,5.96,15.84,
niacin 500 mg ER Tab [FMC],2573343,CDM,250,RC,,,OUTPATIENT,1,EA,13.77,8.262,,11.7,85,,9.36,Percent of total billed charges,85% of total billed charges,6.89,50,,4.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.89,50,,1709.2,percent of total billed charges,50% of total billed charges,4.4,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,4.4,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.23,38,,4.184,percent of total billed charges,38% of total billed charges,5.51,40,,13.728,percent of total billed charges,40% of total billed charges,4.4,11.7,
lisinopril 20 mg Tab [FMC],2573400,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,191.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,104.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,249.208,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,249.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,312,percent of total billed charges,40% of total billed charges,0.96,2.55,
lisinopril 20 mg Tab [FMC],2573400,CDM,250,RC,,,OUTPATIENT,1,EA,4.3,2.58,,3.66,85,,2.928,Percent of total billed charges,85% of total billed charges,2.15,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.15,50,,104.8,percent of total billed charges,50% of total billed charges,1.37,31.95,,239.24,percent of total billed charges,31.95% of total billed charges,1.37,31.95,,239.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.63,38,,1.304,percent of total billed charges,38% of total billed charges,1.72,40,,299.52,percent of total billed charges,40% of total billed charges,1.37,3.66,
lisinopril 20 mg Tab [FMC],2573400,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,104.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,224.04,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,224.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,280.488,percent of total billed charges,40% of total billed charges,0.96,2.55,
lisinopril 20 mg Tab [FMC],2573400,CDM,250,RC,,,OUTPATIENT,1,EA,3.46,2.076,,2.94,85,,2.352,Percent of total billed charges,85% of total billed charges,1.73,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.73,50,,104.8,percent of total billed charges,50% of total billed charges,1.11,31.95,,224.288,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,224.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,280.8,percent of total billed charges,40% of total billed charges,1.11,2.94,
morphine 15 mg IR Tab [FMC],2573442,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,104.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,224.288,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,224.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,280.8,percent of total billed charges,40% of total billed charges,1.28,3.4,
morphine 15 mg IR Tab [FMC],2573442,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,154,percent of total billed charges,50% of total billed charges,1.28,31.95,,466.2,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,466.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,583.656,percent of total billed charges,40% of total billed charges,1.28,3.4,
dextromethorphan-guaiFENesin 30 mg-600 mg ER Tab [FMC],2573483,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,154,percent of total billed charges,50% of total billed charges,0.96,31.95,,92.632,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,92.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,115.976,percent of total billed charges,40% of total billed charges,0.96,2.55,
dextromethorphan-guaiFENesin 30 mg-600 mg ER Tab [FMC],2573483,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,154,percent of total billed charges,50% of total billed charges,0.96,31.95,,120.632,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,109.656,percent of total billed charges,40% of total billed charges,0.96,2.55,
lidocaine 2% Inj Soln MDV 50 mL [FMC],2573491,CDM,250,RC,J2003,HCPCS,OUTPATIENT,50,ML,14.86,8.916,,12.63,85,,10.104,Percent of total billed charges,85% of total billed charges,7.43,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.43,50,,154,percent of total billed charges,50% of total billed charges,5.22,35.15,,206.176,percent of total billed charges,35.15% of total billed charges,55.59,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.65,38,,4.52,percent of total billed charges,38% of total billed charges,4.75,31.95,,187.408,percent of total billed charges,31.95% of total billed charges,4.75,55.59,
lidocaine 2% Inj Soln MDV 50 mL [FMC],2573491,CDM,250,RC,J2003,HCPCS,OUTPATIENT,50,ML,14.35,8.61,,12.2,85,,9.76,Percent of total billed charges,85% of total billed charges,7.18,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.18,50,,154,percent of total billed charges,50% of total billed charges,5.04,35.15,,164.504,percent of total billed charges,35.15% of total billed charges,55.59,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.45,38,,4.36,percent of total billed charges,38% of total billed charges,4.58,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,4.58,55.59,
midazolam 2 mg/mL Oral Syrup [FMC],2573533,CDM,250,RC,,,OUTPATIENT,1,ML,3.5,2.1,,2.98,85,,2.384,Percent of total billed charges,85% of total billed charges,1.75,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.75,50,,154,percent of total billed charges,50% of total billed charges,1.12,31.95,,65.8,percent of total billed charges,31.95% of total billed charges,1.12,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.33,38,,1.064,percent of total billed charges,38% of total billed charges,1.4,40,,59.808,percent of total billed charges,40% of total billed charges,1.12,2.98,
sodium hypochlorite Top 0.25% Sol [FMC],2573588,CDM,250,RC,,,OUTPATIENT,473,EA,36.89,22.134,,31.36,85,,25.088,Percent of total billed charges,85% of total billed charges,18.45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.45,50,,412,percent of total billed charges,50% of total billed charges,11.79,31.95,,11.072,percent of total billed charges,31.95% of total billed charges,11.79,31.95,,11.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.02,38,,11.216,percent of total billed charges,38% of total billed charges,14.76,40,,13.864,percent of total billed charges,40% of total billed charges,11.79,31.36,
sodium hypochlorite Top 0.25% Sol [FMC],2573588,CDM,250,RC,,,OUTPATIENT,473,EA,36.89,22.134,,31.36,85,,25.088,Percent of total billed charges,85% of total billed charges,18.45,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.45,50,,412,percent of total billed charges,50% of total billed charges,11.79,31.95,,123.992,percent of total billed charges,31.95% of total billed charges,11.79,31.95,,123.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.02,38,,11.216,percent of total billed charges,38% of total billed charges,14.76,40,,155.232,percent of total billed charges,40% of total billed charges,11.79,31.36,
lubiprostone 8 mcg Cap [FMC],2573665,CDM,250,RC,,,OUTPATIENT,1,EA,24.12,14.472,,20.5,85,,16.4,Percent of total billed charges,85% of total billed charges,12.06,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.06,50,,412,percent of total billed charges,50% of total billed charges,7.71,31.95,,152.016,percent of total billed charges,31.95% of total billed charges,7.71,31.95,,152.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.17,38,,7.336,percent of total billed charges,38% of total billed charges,9.65,40,,190.32,percent of total billed charges,40% of total billed charges,7.71,20.5,
lubiprostone 8 mcg Cap [FMC],2573665,CDM,250,RC,,,OUTPATIENT,1,EA,22.92,13.752,,19.48,85,,15.584,Percent of total billed charges,85% of total billed charges,11.46,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.46,50,,890,percent of total billed charges,50% of total billed charges,7.32,31.95,,152.576,percent of total billed charges,31.95% of total billed charges,7.32,31.95,,152.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.71,38,,6.968,percent of total billed charges,38% of total billed charges,9.17,40,,191.016,percent of total billed charges,40% of total billed charges,7.32,19.48,
"rivastigmine 9.5 mg/24 hr TD film, ER [FMC]",2573871,CDM,250,RC,,,OUTPATIENT,1,EA,89.18,53.508,,75.8,85,,60.64,Percent of total billed charges,85% of total billed charges,44.59,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.59,50,,412,percent of total billed charges,50% of total billed charges,28.49,31.95,,6.952,percent of total billed charges,31.95% of total billed charges,28.49,31.95,,6.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.89,38,,27.112,percent of total billed charges,38% of total billed charges,35.67,40,,8.704,percent of total billed charges,40% of total billed charges,28.49,75.8,
"rivastigmine 9.5 mg/24 hr TD film, ER [FMC]",2573871,CDM,250,RC,,,OUTPATIENT,1,EA,52.66,31.596,,44.76,85,,35.808,Percent of total billed charges,85% of total billed charges,26.33,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.33,50,,412,percent of total billed charges,50% of total billed charges,16.82,31.95,,152.568,percent of total billed charges,31.95% of total billed charges,16.82,31.95,,152.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.01,38,,16.008,percent of total billed charges,38% of total billed charges,21.06,40,,191.008,percent of total billed charges,40% of total billed charges,16.82,44.76,
"rivastigmine 9.5 mg/24 hr TD film, ER [FMC]",2573871,CDM,250,RC,,,OUTPATIENT,1,EA,54.91,32.946,,46.67,85,,37.336,Percent of total billed charges,85% of total billed charges,27.46,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.46,50,,412,percent of total billed charges,50% of total billed charges,17.54,31.95,,6.264,percent of total billed charges,31.95% of total billed charges,17.54,31.95,,6.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.87,38,,16.696,percent of total billed charges,38% of total billed charges,21.96,40,,7.84,percent of total billed charges,40% of total billed charges,17.54,46.67,
sitaGLIPdtin 50mg Tab UD{FMC},2573889,CDM,250,RC,,,OUTPATIENT,1,EA,42.98,25.788,,36.53,85,,29.224,Percent of total billed charges,85% of total billed charges,21.49,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.49,50,,412,percent of total billed charges,50% of total billed charges,13.73,31.95,,169.464,percent of total billed charges,31.95% of total billed charges,13.73,31.95,,169.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.33,38,,13.064,percent of total billed charges,38% of total billed charges,17.19,40,,212.16,percent of total billed charges,40% of total billed charges,13.73,36.53,
sitaGLIPdtin 50mg Tab UD{FMC},2573889,CDM,250,RC,,,OUTPATIENT,1,EA,67.78,40.668,,57.61,85,,46.088,Percent of total billed charges,85% of total billed charges,33.89,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.89,50,,22,percent of total billed charges,50% of total billed charges,21.66,31.95,,101.328,percent of total billed charges,31.95% of total billed charges,21.66,31.95,,101.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.76,38,,20.608,percent of total billed charges,38% of total billed charges,27.11,40,,126.864,percent of total billed charges,40% of total billed charges,21.66,57.61,
tetanus diphth pertuss adult adol 5 units-2 units-15.5 mcg/0.5 mL Sus [FMC],2573897,CDM,250,RC,,,OUTPATIENT,0.5,ML,167.87,100.722,,142.69,85,,114.152,Percent of total billed charges,85% of total billed charges,83.94,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,83.94,50,,24,percent of total billed charges,50% of total billed charges,53.63,31.95,,101.328,percent of total billed charges,31.95% of total billed charges,53.63,31.95,,101.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.79,38,,51.032,percent of total billed charges,38% of total billed charges,67.15,40,,126.864,percent of total billed charges,40% of total billed charges,53.63,142.69,
tetanus diphth pertuss adult adol 5 units-2 units-15.5 mcg/0.5 mL Sus [FMC],2573897,CDM,250,RC,,,OUTPATIENT,0.5,ML,184.63,110.778,,156.94,85,,125.552,Percent of total billed charges,85% of total billed charges,92.32,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,92.32,50,,27.2,percent of total billed charges,50% of total billed charges,58.99,31.95,,58.016,percent of total billed charges,31.95% of total billed charges,58.99,31.95,,58.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.16,38,,56.128,percent of total billed charges,38% of total billed charges,73.85,40,,72.632,percent of total billed charges,40% of total billed charges,58.99,156.94,
inFLIXimab 100 mg IV Inj [FMC],2573913,CDM,250,RC,J1745,HCPCS,OUTPATIENT,1,EA,4554.49,2732.694,,3871.32,85,,3097.056,Percent of total billed charges,85% of total billed charges,49.04,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.04,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,1600.9,35.15,,48.648,fee schedule,35.15% of LA custom fee schedule,1455.16,31.95,,48.648,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1730.71,38,,1384.568,percent of total billed charges,38% of total billed charges,1455.16,31.95,,60.904,Fee Schedule,31.95% of LA custom fee schedule,49.04,3871.32,
diclofenac Top 1% gel [FMC],2573947,CDM,250,RC,,,OUTPATIENT,100,EA,117.66,70.596,,100.01,85,,80.008,Percent of total billed charges,85% of total billed charges,58.83,50,,54.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,58.83,50,,102.4,percent of total billed charges,50% of total billed charges,37.59,31.95,,34.472,percent of total billed charges,31.95% of total billed charges,37.59,31.95,,34.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.71,38,,35.768,percent of total billed charges,38% of total billed charges,47.06,40,,43.16,percent of total billed charges,40% of total billed charges,37.59,100.01,
diclofenac Top 1% gel [FMC],2573947,CDM,250,RC,,,OUTPATIENT,100,EA,178.17,106.902,,151.44,85,,121.152,Percent of total billed charges,85% of total billed charges,89.09,50,,1161.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,89.09,50,,25.6,percent of total billed charges,50% of total billed charges,56.93,31.95,,34.472,percent of total billed charges,31.95% of total billed charges,56.93,31.95,,34.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,67.7,38,,54.16,percent of total billed charges,38% of total billed charges,71.27,40,,43.16,percent of total billed charges,40% of total billed charges,56.93,151.44,
diclofenac Top 1% gel [FMC],2573947,CDM,250,RC,,,OUTPATIENT,100,EA,171.02,102.612,,145.37,85,,116.296,Percent of total billed charges,85% of total billed charges,85.51,50,,104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85.51,50,,72.4,percent of total billed charges,50% of total billed charges,54.64,31.95,,37.568,percent of total billed charges,31.95% of total billed charges,54.64,31.95,,37.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.99,38,,51.992,percent of total billed charges,38% of total billed charges,68.41,40,,47.032,percent of total billed charges,40% of total billed charges,54.64,145.37,
diclofenac Top 1% gel [FMC],2573947,CDM,250,RC,,,OUTPATIENT,100,EA,53.14,31.884,,45.17,85,,36.136,Percent of total billed charges,85% of total billed charges,26.57,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.57,50,,12,percent of total billed charges,50% of total billed charges,16.98,31.95,,20.752,percent of total billed charges,31.95% of total billed charges,16.98,31.95,,20.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.19,38,,16.152,percent of total billed charges,38% of total billed charges,21.26,40,,25.984,percent of total billed charges,40% of total billed charges,16.98,45.17,
desvenlafaxine 50 mg ER [FMC],2574010,CDM,250,RC,,,OUTPATIENT,1,EA,24.78,14.868,,21.06,85,,16.848,Percent of total billed charges,85% of total billed charges,12.39,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.39,50,,168.8,percent of total billed charges,50% of total billed charges,7.92,31.95,,11.96,percent of total billed charges,31.95% of total billed charges,7.92,31.95,,11.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.42,38,,7.536,percent of total billed charges,38% of total billed charges,9.91,40,,14.976,percent of total billed charges,40% of total billed charges,7.92,21.06,
desvenlafaxine 50 mg ER [FMC],2574010,CDM,250,RC,,,OUTPATIENT,1,EA,24.78,14.868,,21.06,85,,16.848,Percent of total billed charges,85% of total billed charges,12.39,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.39,50,,6,percent of total billed charges,50% of total billed charges,7.92,31.95,,20.936,percent of total billed charges,31.95% of total billed charges,7.92,31.95,,20.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.42,38,,7.536,percent of total billed charges,38% of total billed charges,9.91,40,,26.208,percent of total billed charges,40% of total billed charges,7.92,21.06,
desvenlafaxine 50 mg ER [FMC],2574010,CDM,250,RC,,,OUTPATIENT,1,EA,37.27,22.362,,31.68,85,,25.344,Percent of total billed charges,85% of total billed charges,18.64,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.64,50,,103.2,percent of total billed charges,50% of total billed charges,11.91,31.95,,7.232,percent of total billed charges,31.95% of total billed charges,11.91,31.95,,7.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.16,38,,11.328,percent of total billed charges,38% of total billed charges,14.91,40,,9.048,percent of total billed charges,40% of total billed charges,11.91,31.68,
desvenlafaxine 50 mg ER [FMC],2574010,CDM,250,RC,,,OUTPATIENT,1,EA,37.29,22.374,,31.7,85,,25.36,Percent of total billed charges,85% of total billed charges,18.65,50,,280,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.65,50,,10,percent of total billed charges,50% of total billed charges,11.91,31.95,,11.464,percent of total billed charges,31.95% of total billed charges,11.91,31.95,,11.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.17,38,,11.336,percent of total billed charges,38% of total billed charges,14.92,40,,14.352,percent of total billed charges,40% of total billed charges,11.91,31.7,
desvenlafaxine 50 mg ER [FMC],2574010,CDM,250,RC,,,OUTPATIENT,1,EA,35.79,21.474,,30.42,85,,24.336,Percent of total billed charges,85% of total billed charges,17.9,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.9,50,,70,percent of total billed charges,50% of total billed charges,11.43,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,11.43,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.6,38,,10.88,percent of total billed charges,38% of total billed charges,14.32,40,,1.28,percent of total billed charges,40% of total billed charges,11.43,30.42,
Penicillin V Potassium 250 mg/5 mL REC [FMC],2574135,CDM,250,RC,,,OUTPATIENT,100,ML,33.28,19.968,,28.29,85,,22.632,Percent of total billed charges,85% of total billed charges,16.64,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.64,50,,100,percent of total billed charges,50% of total billed charges,10.63,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,10.63,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.65,38,,10.12,percent of total billed charges,38% of total billed charges,13.31,40,,1.28,percent of total billed charges,40% of total billed charges,10.63,28.29,
calamine Top 8% Lotion [FMC],2574143,CDM,250,RC,,,OUTPATIENT,120,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,240,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,112,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.28,percent of total billed charges,40% of total billed charges,1.92,5.1,
trandolapril 2 mg Tab [FMC],2574218,CDM,250,RC,,,OUTPATIENT,1,EA,4.03,2.418,,3.43,85,,2.744,Percent of total billed charges,85% of total billed charges,2.02,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.02,50,,98.4,percent of total billed charges,50% of total billed charges,1.29,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.29,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.53,38,,1.224,percent of total billed charges,38% of total billed charges,1.61,40,,1.28,percent of total billed charges,40% of total billed charges,1.29,3.43,
trandolapril 2 mg Tab [FMC],2574218,CDM,250,RC,,,OUTPATIENT,1,EA,4.03,2.418,,3.43,85,,2.744,Percent of total billed charges,85% of total billed charges,2.02,50,,196,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.02,50,,86.4,percent of total billed charges,50% of total billed charges,1.29,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.29,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.53,38,,1.224,percent of total billed charges,38% of total billed charges,1.61,40,,1.28,percent of total billed charges,40% of total billed charges,1.29,3.43,
ziprasidone 20 mg IM Inj [FMC],2574267,CDM,250,RC,J3486,HCPCS,OUTPATIENT,1,EA,223.65,134.19,,190.1,85,,152.08,Percent of total billed charges,85% of total billed charges,14.96,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.96,136.6,,110.8,fee schedule,136.60% of BCBS custom fee schedule,78.61,35.15,,467.904,percent of total billed charges,35.15% of total billed charges,55.59,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,84.99,38,,67.992,percent of total billed charges,38% of total billed charges,71.46,31.95,,425.312,percent of total billed charges,31.95% of total billed charges,14.96,190.1,
ziprasidone 20 mg IM Inj [FMC],2574267,CDM,250,RC,J3486,HCPCS,OUTPATIENT,1,EA,213.21,127.926,,181.23,85,,144.984,Percent of total billed charges,85% of total billed charges,14.96,136.6,,57.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.96,136.6,,34.8,fee schedule,136.60% of BCBS custom fee schedule,74.94,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,57.02,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,81.02,38,,64.816,percent of total billed charges,38% of total billed charges,68.12,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,14.96,181.23,
ziprasidone 20 mg IM Inj [FMC],2574267,CDM,250,RC,J3486,HCPCS,OUTPATIENT,1,EA,183.3,109.98,,155.81,85,,124.648,Percent of total billed charges,85% of total billed charges,14.96,136.6,,150,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.96,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,64.43,35.15,,644.296,percent of total billed charges,35.15% of total billed charges,57.02,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.65,38,,55.72,percent of total billed charges,38% of total billed charges,58.56,31.95,,585.64,percent of total billed charges,31.95% of total billed charges,14.96,155.81,
ziprasidone 20 mg IM Inj [FMC],2574267,CDM,250,RC,J3486,HCPCS,OUTPATIENT,1,EA,127.88,76.728,,108.7,85,,86.96,Percent of total billed charges,85% of total billed charges,14.96,136.6,,214,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.96,136.6,,194.8,fee schedule,136.60% of BCBS custom fee schedule,44.95,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,57.51,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.59,38,,38.872,percent of total billed charges,38% of total billed charges,40.86,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,14.96,108.7,
diphenhydrAMINE 25 mg Cap [FMC],2574317,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,160,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,84,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
diphenhydrAMINE 25 mg Cap [FMC],2574317,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,178.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
vitamin and mineral eye supplement Tab [FMC],2574325,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,202.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,10,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
ferrous sulfate 300 mg/5 mL ORAL Liq UD [FMC],2574333,CDM,250,RC,,,OUTPATIENT,5,ML,14.49,8.694,,12.32,85,,9.856,Percent of total billed charges,85% of total billed charges,7.25,50,,199.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.25,50,,186,percent of total billed charges,50% of total billed charges,4.63,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,4.63,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.51,38,,4.408,percent of total billed charges,38% of total billed charges,5.8,40,,1.28,percent of total billed charges,40% of total billed charges,4.63,12.32,
docusate calcium 240 mg Cap [FMC],2574341,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,158,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4000,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate calcium 240 mg Cap [FMC],2574341,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,244.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,186,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate calcium 240 mg Cap [FMC],2574341,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,352.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,1.92,percent of total billed charges,40% of total billed charges,0.96,2.55,
docusate calcium 240 mg Cap [FMC],2574341,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,319.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,184.192,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,167.424,percent of total billed charges,40% of total billed charges,0.96,2.55,
zoledronic acid 5 mg/100 mL IV Sol [FMC],2581213,CDM,250,RC,J3489,HCPCS,OUTPATIENT,100,ML,3230.76,1938.456,,2746.15,85,,2196.92,Percent of total billed charges,85% of total billed charges,10.41,136.6,,116,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.41,136.6,,516.8,fee schedule,136.60% of BCBS custom fee schedule,1135.61,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,1032.23,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1227.69,38,,982.152,percent of total billed charges,38% of total billed charges,1032.23,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,10.41,2746.15,
zoledronic acid 5 mg/100 mL IV Sol [FMC],2581213,CDM,250,RC,J3489,HCPCS,OUTPATIENT,100,ML,3842.67,2305.602,,3266.27,85,,2613.016,Percent of total billed charges,85% of total billed charges,10.41,136.6,,6.088,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.41,136.6,,380.4,fee schedule,136.60% of BCBS custom fee schedule,1350.7,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,1227.73,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1460.21,38,,1168.168,percent of total billed charges,38% of total billed charges,1227.73,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,10.41,3266.27,
zoledronic acid 5 mg/100 mL IV Sol [FMC],2581213,CDM,250,RC,J3489,HCPCS,OUTPATIENT,100,ML,1170,702,,994.5,85,,795.6,Percent of total billed charges,85% of total billed charges,10.41,136.6,,65.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.41,136.6,,258.4,fee schedule,136.60% of BCBS custom fee schedule,411.26,35.15,,115.056,fee schedule,35.15% of LA custom fee schedule,373.82,31.95,,115.056,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,444.6,38,,355.68,percent of total billed charges,38% of total billed charges,373.82,31.95,,144.048,Fee Schedule,31.95% of LA custom fee schedule,10.41,994.5,
zoledronic acid 5 mg/100 mL IV Sol [FMC],2581213,CDM,250,RC,J3489,HCPCS,OUTPATIENT,100,ML,1365,819,,1160.25,85,,928.2,Percent of total billed charges,85% of total billed charges,10.41,136.6,,128.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.41,136.6,,302.8,fee schedule,136.60% of BCBS custom fee schedule,479.8,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,436.12,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,518.7,38,,414.96,percent of total billed charges,38% of total billed charges,436.12,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,10.41,1160.25,
oxytocin 10 units/mL Sol [FMC],2581304,CDM,250,RC,J2590,HCPCS,OUTPATIENT,1,ML,14.04,8.424,,11.93,85,,9.544,Percent of total billed charges,85% of total billed charges,1.35,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.35,136.6,,574.4,fee schedule,136.60% of BCBS custom fee schedule,4.94,35.15,,28.912,percent of total billed charges,35.15% of total billed charges,57.51,31.95,,28.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.34,38,,4.272,percent of total billed charges,38% of total billed charges,4.49,31.95,,36.192,percent of total billed charges,31.95% of total billed charges,1.35,57.51,
"Vitamin D2 50,000 intl units Cap [FMC]",2581312,CDM,250,RC,,,OUTPATIENT,1,EA,6.41,3.846,,5.45,85,,4.36,Percent of total billed charges,85% of total billed charges,3.21,50,,93.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.21,50,,322.4,percent of total billed charges,50% of total billed charges,2.05,31.95,,28.912,percent of total billed charges,31.95% of total billed charges,2.05,31.95,,28.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.44,38,,1.952,percent of total billed charges,38% of total billed charges,2.56,40,,36.192,percent of total billed charges,40% of total billed charges,2.05,5.45,
"Vitamin D2 50,000 intl units Cap [FMC]",2581312,CDM,250,RC,,,OUTPATIENT,1,EA,6.24,3.744,,5.3,85,,4.24,Percent of total billed charges,85% of total billed charges,3.12,50,,64.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.12,50,,1558.8,percent of total billed charges,50% of total billed charges,1.99,31.95,,26.024,percent of total billed charges,31.95% of total billed charges,1.99,31.95,,26.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.37,38,,1.896,percent of total billed charges,38% of total billed charges,2.5,40,,32.576,percent of total billed charges,40% of total billed charges,1.99,5.3,
methenamine hippurate 1 g Tab [FMC],2581320,CDM,250,RC,,,OUTPATIENT,1,EA,6.8,4.08,,5.78,85,,4.624,Percent of total billed charges,85% of total billed charges,3.4,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.4,50,,368.4,percent of total billed charges,50% of total billed charges,2.17,31.95,,26.008,percent of total billed charges,31.95% of total billed charges,2.17,31.95,,26.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.58,38,,2.064,percent of total billed charges,38% of total billed charges,2.72,40,,32.56,percent of total billed charges,40% of total billed charges,2.17,5.78,
methenamine hippurate 1 g Tab [FMC],2581320,CDM,250,RC,,,OUTPATIENT,1,EA,6.8,4.08,,5.78,85,,4.624,Percent of total billed charges,85% of total billed charges,3.4,50,,60.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.4,50,,442.4,percent of total billed charges,50% of total billed charges,2.17,31.95,,26.008,percent of total billed charges,31.95% of total billed charges,2.17,31.95,,26.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.58,38,,2.064,percent of total billed charges,38% of total billed charges,2.72,40,,32.56,percent of total billed charges,40% of total billed charges,2.17,5.78,
methenamine hippurate 1 g Tab [FMC],2581320,CDM,250,RC,,,OUTPATIENT,1,EA,6.8,4.08,,5.78,85,,4.624,Percent of total billed charges,85% of total billed charges,3.4,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.4,50,,116.4,percent of total billed charges,50% of total billed charges,2.17,31.95,,26.008,percent of total billed charges,31.95% of total billed charges,2.17,31.95,,26.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.58,38,,2.064,percent of total billed charges,38% of total billed charges,2.72,40,,32.56,percent of total billed charges,40% of total billed charges,2.17,5.78,
acyclovir Top 5% Oint [FMC],2581403,CDM,250,RC,,,OUTPATIENT,15,EA,1296.1,777.66,,1101.69,85,,881.352,Percent of total billed charges,85% of total billed charges,648.05,50,,115.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,648.05,50,,200,percent of total billed charges,50% of total billed charges,414.1,31.95,,20.976,percent of total billed charges,31.95% of total billed charges,414.1,31.95,,20.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,492.52,38,,394.016,percent of total billed charges,38% of total billed charges,518.44,40,,26.256,percent of total billed charges,40% of total billed charges,414.1,1101.69,
acyclovir Top 5% Oint [FMC],2581403,CDM,250,RC,,,OUTPATIENT,15,EA,1296.1,777.66,,1101.69,85,,881.352,Percent of total billed charges,85% of total billed charges,648.05,50,,32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,648.05,50,,12,percent of total billed charges,50% of total billed charges,414.1,31.95,,2.024,percent of total billed charges,31.95% of total billed charges,414.1,31.95,,2.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,492.52,38,,394.016,percent of total billed charges,38% of total billed charges,518.44,40,,2.536,percent of total billed charges,40% of total billed charges,414.1,1101.69,
permethrin Top 1% lotion [FMC],2581429,CDM,250,RC,,,OUTPATIENT,60,EA,26.62,15.972,,22.63,85,,18.104,Percent of total billed charges,85% of total billed charges,13.31,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.31,50,,20,percent of total billed charges,50% of total billed charges,8.51,31.95,,15.248,percent of total billed charges,31.95% of total billed charges,8.51,31.95,,15.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.12,38,,8.096,percent of total billed charges,38% of total billed charges,10.65,40,,19.088,percent of total billed charges,40% of total billed charges,8.51,22.63,
Permethrine lice cr?me rinse [FMC],2581429,CDM,250,RC,,,OUTPATIENT,60,EA,50.62,30.372,,43.03,85,,34.424,Percent of total billed charges,85% of total billed charges,25.31,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.31,50,,43.2,percent of total billed charges,50% of total billed charges,16.17,31.95,,15.392,percent of total billed charges,31.95% of total billed charges,16.17,31.95,,15.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.24,38,,15.392,percent of total billed charges,38% of total billed charges,20.25,40,,19.272,percent of total billed charges,40% of total billed charges,16.17,43.03,
benzoin compound Top tincture [FMC],2581445,CDM,250,RC,,,OUTPATIENT,60,EA,17.31,10.386,,14.71,85,,11.768,Percent of total billed charges,85% of total billed charges,8.66,50,,77.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.66,50,,45.6,percent of total billed charges,50% of total billed charges,5.53,31.95,,15.248,percent of total billed charges,31.95% of total billed charges,5.53,31.95,,15.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.58,38,,5.264,percent of total billed charges,38% of total billed charges,6.92,40,,19.088,percent of total billed charges,40% of total billed charges,5.53,14.71,
benzoin compound Top tincture [FMC],2581445,CDM,250,RC,,,OUTPATIENT,60,EA,32.43,19.458,,27.57,85,,22.056,Percent of total billed charges,85% of total billed charges,16.22,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.22,50,,82,percent of total billed charges,50% of total billed charges,10.36,31.95,,2.256,percent of total billed charges,31.95% of total billed charges,10.36,31.95,,2.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.32,38,,9.856,percent of total billed charges,38% of total billed charges,12.97,40,,2.824,percent of total billed charges,40% of total billed charges,10.36,27.57,
calcium oyster 500 with Vit D 500mg/200units Tab UD [FMC],2581478,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,67.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.184,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.736,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium oyster 500 with Vit D 500mg/200units Tab UD [FMC],2581478,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,655.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.024,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.792,percent of total billed charges,40% of total billed charges,0.96,2.55,
calcium oyster 500 with Vit D 500mg/200units Tab UD [FMC],2581478,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,255.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.704,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,2.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.384,percent of total billed charges,40% of total billed charges,0.96,2.55,
tobramycin 0.3 % Ointment,2581486,CDM,250,RC,,,OUTPATIENT,1,EA,877.83,526.698,,746.16,85,,596.928,Percent of total billed charges,85% of total billed charges,438.92,50,,255.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,438.92,50,,1260,percent of total billed charges,50% of total billed charges,280.47,31.95,,70.64,percent of total billed charges,31.95% of total billed charges,280.47,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,333.58,38,,266.864,percent of total billed charges,38% of total billed charges,351.13,40,,64.208,percent of total billed charges,40% of total billed charges,280.47,746.16,
fosphenytoin 100 mg PE/2 mL Sol [FMC],2581494,CDM,250,RC,Q2009,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6.79,136.6,,1260,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.79,136.6,,960,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,17.944,percent of total billed charges,35.15% of total billed charges,57.51,31.95,,17.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,22.464,percent of total billed charges,31.95% of total billed charges,3.83,57.51,
fosphenytoin 100 mg PE/2 mL Sol [FMC],2581494,CDM,250,RC,Q2009,HCPCS,OUTPATIENT,2,ML,102.12,61.272,,86.8,85,,69.44,Percent of total billed charges,85% of total billed charges,6.79,136.6,,960,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.79,136.6,,150,fee schedule,136.60% of BCBS custom fee schedule,35.9,35.15,,25.352,percent of total billed charges,35.15% of total billed charges,57.51,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.81,38,,31.048,percent of total billed charges,38% of total billed charges,32.63,31.95,,23.048,percent of total billed charges,31.95% of total billed charges,6.79,86.8,
isopropyl alcohol otic 95% Liq [FMC],2581502,CDM,250,RC,,,OUTPATIENT,30,EA,14.14,8.484,,12.02,85,,9.616,Percent of total billed charges,85% of total billed charges,7.07,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.07,50,,20,percent of total billed charges,50% of total billed charges,4.52,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,4.52,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.37,38,,4.296,percent of total billed charges,38% of total billed charges,5.66,40,,5.28,percent of total billed charges,40% of total billed charges,4.52,12.02,
carbamide peroxide Otic 6.5% Sol [FMC],2581510,CDM,250,RC,,,OUTPATIENT,15,EA,8.06,4.836,,6.85,85,,5.48,Percent of total billed charges,85% of total billed charges,4.03,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.03,50,,22.376,percent of total billed charges,50% of total billed charges,2.58,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,2.58,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.06,38,,2.448,percent of total billed charges,38% of total billed charges,3.22,40,,0.96,percent of total billed charges,40% of total billed charges,2.58,6.85,
carbamide peroxide Otic 6.5% Sol [FMC],2581510,CDM,250,RC,,,OUTPATIENT,15,EA,14.92,8.952,,12.68,85,,10.144,Percent of total billed charges,85% of total billed charges,7.46,50,,22.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.46,50,,24,percent of total billed charges,50% of total billed charges,4.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.77,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.67,38,,4.536,percent of total billed charges,38% of total billed charges,5.97,40,,0.96,percent of total billed charges,40% of total billed charges,4.77,12.68,
carbamide peroxide Otic 6.5% Sol [FMC],2581510,CDM,250,RC,,,OUTPATIENT,15,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,680,percent of total billed charges,50% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,0.96,percent of total billed charges,40% of total billed charges,1.92,5.1,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [FMC]C,2581528,CDM,250,RC,J0702,HCPCS,OUTPATIENT,1,ML,40.88,24.528,,34.75,85,,27.8,Percent of total billed charges,85% of total billed charges,9.63,136.6,,680,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.63,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,14.37,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,57.51,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.53,38,,12.424,percent of total billed charges,38% of total billed charges,13.06,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,9.63,57.51,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [FMC],2581528,CDM,250,RC,J0702,HCPCS,OUTPATIENT,1,ML,29.17,17.502,,24.79,85,,19.832,Percent of total billed charges,85% of total billed charges,9.63,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.63,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,10.25,35.15,,17.592,percent of total billed charges,35.15% of total billed charges,57.83,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.08,38,,8.864,percent of total billed charges,38% of total billed charges,9.32,31.95,,15.992,percent of total billed charges,31.95% of total billed charges,9.32,57.83,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [FMC,2581528,CDM,250,RC,J0702,HCPCS,OUTPATIENT,1,ML,31.2,18.72,,26.52,85,,21.216,Percent of total billed charges,85% of total billed charges,9.63,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.63,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,10.97,35.15,,17.592,percent of total billed charges,35.15% of total billed charges,57.83,31.95,,61.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.86,38,,9.488,percent of total billed charges,38% of total billed charges,9.97,31.95,,15.992,percent of total billed charges,31.95% of total billed charges,9.63,57.83,
betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL [FMC]C,2581528,CDM,250,RC,J0702,HCPCS,OUTPATIENT,1,ML,31.4,18.84,,26.69,85,,21.352,Percent of total billed charges,85% of total billed charges,9.63,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.63,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,11.04,35.15,,16.232,percent of total billed charges,35.15% of total billed charges,57.83,31.95,,61.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.93,38,,9.544,percent of total billed charges,38% of total billed charges,10.03,31.95,,14.752,percent of total billed charges,31.95% of total billed charges,9.63,57.83,
Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [FMC],2581569,CDM,250,RC,J3480,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,18.368,percent of total billed charges,35.15% of total billed charges,58.15,31.95,,62.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,16.696,percent of total billed charges,31.95% of total billed charges,0.16,58.15,
Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [FMC],2581569,CDM,250,RC,J3480,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,7.256,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,58.15,31.95,,62.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.16,58.15,
Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [FMC],2581569,CDM,250,RC,J3480,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.16,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.16,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,58.15,31.95,,63.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,0.16,58.15,
tolterodine 4 mg ERCap [FMC],2581635,CDM,250,RC,,,OUTPATIENT,1,EA,26.09,15.654,,22.18,85,,17.744,Percent of total billed charges,85% of total billed charges,13.05,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.05,50,,4.8,percent of total billed charges,50% of total billed charges,8.34,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,8.34,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.91,38,,7.928,percent of total billed charges,38% of total billed charges,10.44,40,,3.064,percent of total billed charges,40% of total billed charges,8.34,22.18,
tolterodine 4 mg ERCap [FMC],2581635,CDM,250,RC,,,OUTPATIENT,1,EA,26.12,15.672,,22.2,85,,17.76,Percent of total billed charges,85% of total billed charges,13.06,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.06,50,,4.8,percent of total billed charges,50% of total billed charges,8.35,31.95,,2.264,percent of total billed charges,31.95% of total billed charges,8.35,31.95,,2.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.93,38,,7.944,percent of total billed charges,38% of total billed charges,10.45,40,,2.84,percent of total billed charges,40% of total billed charges,8.35,22.2,
tolterodine 4 mg ERCap [FMC],2581635,CDM,250,RC,,,OUTPATIENT,1,EA,26.09,15.654,,22.18,85,,17.744,Percent of total billed charges,85% of total billed charges,13.05,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.05,50,,4.8,percent of total billed charges,50% of total billed charges,8.34,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,8.34,31.95,,0.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.91,38,,7.928,percent of total billed charges,38% of total billed charges,10.44,40,,1.104,percent of total billed charges,40% of total billed charges,8.34,22.18,
tolterodine 4 mg ERCap [FMC],2581635,CDM,250,RC,,,OUTPATIENT,1,EA,26.12,15.672,,22.2,85,,17.76,Percent of total billed charges,85% of total billed charges,13.06,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.06,50,,4.8,percent of total billed charges,50% of total billed charges,8.35,31.95,,29.072,percent of total billed charges,31.95% of total billed charges,8.35,31.95,,29.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.93,38,,7.944,percent of total billed charges,38% of total billed charges,10.45,40,,36.4,percent of total billed charges,40% of total billed charges,8.35,22.2,
tolterodine 4 mg ERCap [FMC],2581635,CDM,250,RC,,,OUTPATIENT,1,EA,31.03,18.618,,26.38,85,,21.104,Percent of total billed charges,85% of total billed charges,15.52,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.52,50,,4.8,percent of total billed charges,50% of total billed charges,9.91,31.95,,30.736,percent of total billed charges,31.95% of total billed charges,9.91,31.95,,30.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.79,38,,9.432,percent of total billed charges,38% of total billed charges,12.41,40,,38.48,percent of total billed charges,40% of total billed charges,9.91,26.38,
tolterodine 4 mg ERCap [FMC],2581635,CDM,250,RC,,,OUTPATIENT,1,EA,31.24,18.744,,26.55,85,,21.24,Percent of total billed charges,85% of total billed charges,15.62,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.62,50,,4.8,percent of total billed charges,50% of total billed charges,9.98,31.95,,897.52,percent of total billed charges,31.95% of total billed charges,9.98,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.87,38,,9.496,percent of total billed charges,38% of total billed charges,12.5,40,,815.816,percent of total billed charges,40% of total billed charges,9.98,26.55,
cetaphil 236 mL [FMC],2581643,CDM,250,RC,,,OUTPATIENT,236,EA,20.73,12.438,,17.62,85,,14.096,Percent of total billed charges,85% of total billed charges,10.37,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.37,50,,4.8,percent of total billed charges,50% of total billed charges,6.62,31.95,,8.568,percent of total billed charges,31.95% of total billed charges,6.62,31.95,,8.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.88,38,,6.304,percent of total billed charges,38% of total billed charges,8.29,40,,10.728,percent of total billed charges,40% of total billed charges,6.62,17.62,
hydrocortisone 5 mg Tab [FMC],2581692,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,8.168,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,8.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,10.224,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrocortisone 5 mg Tab [FMC],2581692,CDM,250,RC,,,OUTPATIENT,1,EA,3.38,2.028,,2.87,85,,2.296,Percent of total billed charges,85% of total billed charges,1.69,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.69,50,,10.72,percent of total billed charges,50% of total billed charges,1.08,31.95,,10.144,percent of total billed charges,31.95% of total billed charges,1.08,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.28,38,,1.024,percent of total billed charges,38% of total billed charges,1.35,40,,9.224,percent of total billed charges,40% of total billed charges,1.08,2.87,
hydrocortisone 5 mg Tab,2581692,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,10.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,15.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,8.552,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.776,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrocortisone 5 mg Tab [FMC],2581692,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8,percent of total billed charges,50% of total billed charges,0.96,31.95,,55.376,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,55.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,69.328,percent of total billed charges,40% of total billed charges,0.96,2.55,
ondansetron 4 mg DIS UD [FMC],2581726,CDM,250,RC,S0119,HCPCS,OUTPATIENT,1,EA,72.45,43.47,,61.58,85,,49.264,Percent of total billed charges,85% of total billed charges,30.33,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.33,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,25.47,35.15,,55.376,percent of total billed charges,35.15% of total billed charges,58.15,31.95,,55.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.53,38,,22.024,percent of total billed charges,38% of total billed charges,23.15,31.95,,69.328,percent of total billed charges,31.95% of total billed charges,23.15,61.58,
ondansetron 4 mg DIS UD [FMC],2581726,CDM,250,RC,S0119,HCPCS,OUTPATIENT,1,EA,75.12,45.072,,63.85,85,,51.08,Percent of total billed charges,85% of total billed charges,30.33,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.33,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,26.4,35.15,,42.864,percent of total billed charges,35.15% of total billed charges,59.43,31.95,,42.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.55,38,,22.84,percent of total billed charges,38% of total billed charges,24,31.95,,53.664,percent of total billed charges,31.95% of total billed charges,24,63.85,
ondansetron 4 mg DIS UD [FMC],2581726,CDM,250,RC,S0119,HCPCS,OUTPATIENT,1,EA,72.45,43.47,,61.58,85,,49.264,Percent of total billed charges,85% of total billed charges,30.33,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.33,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,25.47,35.15,,44.648,percent of total billed charges,35.15% of total billed charges,59.43,31.95,,44.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.53,38,,22.024,percent of total billed charges,38% of total billed charges,23.15,31.95,,55.904,percent of total billed charges,31.95% of total billed charges,23.15,61.58,
magnesium sulfate 50% Inj Sol 2 mL [FMC],2581759,CDM,250,RC,J3475,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.15,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,9.2,percent of total billed charges,35.15% of total billed charges,59.43,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,11.52,percent of total billed charges,31.95% of total billed charges,1.15,59.43,
magnesium sulfate 50% Inj Sol 2 mL [FMC],2581759,CDM,250,RC,J3475,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.15,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,37.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,9.2,percent of total billed charges,35.15% of total billed charges,62.08,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,11.52,percent of total billed charges,31.95% of total billed charges,1.15,62.08,
collagenase Top 250 units/g Oint [FMC],2581767,CDM,250,RC,J3590,HCPCS,OUTPATIENT,30,EA,724.49,434.694,,615.82,85,,492.656,Percent of total billed charges,85% of total billed charges,362.25,50,,37.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,362.25,50,,36.4,percent of total billed charges,50% of total billed charges,254.66,35.15,,1.536,fee schedule,35.15% of LA custom fee schedule,231.47,31.95,,1.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,275.31,38,,220.248,percent of total billed charges,38% of total billed charges,231.47,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,231.47,615.82,
collagenase Top 250 units/g Oint [FMC],2581767,CDM,250,RC,J3590,HCPCS,OUTPATIENT,30,EA,1069.58,641.748,,909.14,85,,727.312,Percent of total billed charges,85% of total billed charges,534.79,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,534.79,50,,36.4,percent of total billed charges,50% of total billed charges,375.96,35.15,,39.48,fee schedule,35.15% of LA custom fee schedule,341.73,31.95,,6.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,406.44,38,,325.152,percent of total billed charges,38% of total billed charges,341.73,31.95,,35.888,Fee Schedule,31.95% of LA custom fee schedule,341.73,909.14,
midodrine 5 mg Tab UD[FMC],2581783,CDM,250,RC,,,OUTPATIENT,1,EA,13.51,8.106,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.76,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.76,50,,36.4,percent of total billed charges,50% of total billed charges,4.32,31.95,,2.088,percent of total billed charges,31.95% of total billed charges,4.32,31.95,,2.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,4.104,percent of total billed charges,38% of total billed charges,5.4,40,,2.608,percent of total billed charges,40% of total billed charges,4.32,11.48,
midodrine 5 mg Tab UD[FMC],2581783,CDM,250,RC,,,OUTPATIENT,1,EA,8.81,5.286,,7.49,85,,5.992,Percent of total billed charges,85% of total billed charges,4.41,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.41,50,,29.6,percent of total billed charges,50% of total billed charges,2.81,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,2.81,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.35,38,,2.68,percent of total billed charges,38% of total billed charges,3.52,40,,1.92,percent of total billed charges,40% of total billed charges,2.81,7.49,
midodrine 5 mg Tab UD[FMC],2581783,CDM,250,RC,,,OUTPATIENT,1,EA,14.59,8.754,,12.4,85,,9.92,Percent of total billed charges,85% of total billed charges,7.3,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.3,50,,13.2,percent of total billed charges,50% of total billed charges,4.66,31.95,,2.208,percent of total billed charges,31.95% of total billed charges,4.66,31.95,,2.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.54,38,,4.432,percent of total billed charges,38% of total billed charges,5.84,40,,2.768,percent of total billed charges,40% of total billed charges,4.66,12.4,
midodrine 5 mg Tab UD[FMC],2581783,CDM,250,RC,,,OUTPATIENT,1,EA,3.38,2.028,,2.87,85,,2.296,Percent of total billed charges,85% of total billed charges,1.69,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.69,50,,15.2,percent of total billed charges,50% of total billed charges,1.08,31.95,,30.952,percent of total billed charges,31.95% of total billed charges,1.08,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.28,38,,1.024,percent of total billed charges,38% of total billed charges,1.35,40,,28.128,percent of total billed charges,40% of total billed charges,1.08,2.87,
midodrine 5 mg Tab UD[FMC],2581783,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,34.544,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,31.4,percent of total billed charges,40% of total billed charges,0.96,2.55,
dronedarone 400 mg Tab [FMC],2581833,CDM,250,RC,,,OUTPATIENT,1,EA,47.05,28.23,,39.99,85,,31.992,Percent of total billed charges,85% of total billed charges,23.53,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.53,50,,36,percent of total billed charges,50% of total billed charges,15.03,31.95,,46.968,percent of total billed charges,31.95% of total billed charges,15.03,31.95,,46.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.88,38,,14.304,percent of total billed charges,38% of total billed charges,18.82,40,,58.8,percent of total billed charges,40% of total billed charges,15.03,39.99,
dronedarone 400 mg Tab [FMC],2581833,CDM,250,RC,,,OUTPATIENT,1,EA,35.22,21.132,,29.94,85,,23.952,Percent of total billed charges,85% of total billed charges,17.61,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.61,50,,36,percent of total billed charges,50% of total billed charges,11.25,31.95,,43.896,percent of total billed charges,31.95% of total billed charges,11.25,31.95,,43.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.38,38,,10.704,percent of total billed charges,38% of total billed charges,14.09,40,,54.96,percent of total billed charges,40% of total billed charges,11.25,29.94,
insulin glulisine 100 units/mL SC Sol [FMC],2581858,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,66.08,39.648,,56.17,85,,44.936,Percent of total billed charges,85% of total billed charges,0.76,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,28.048,fee schedule,136.60% of BCBS custom fee schedule,23.23,35.15,,11.672,fee schedule,35.15% of LA custom fee schedule,21.11,31.95,,11.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.11,38,,20.088,percent of total billed charges,38% of total billed charges,21.11,31.95,,14.608,Fee Schedule,31.95% of LA custom fee schedule,0.76,56.17,
vitamin D 1000 intl units oral Tab [FMC],2581916,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,28.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,6.112,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,7.648,percent of total billed charges,40% of total billed charges,0.96,2.55,
vitamin D 1000 intl units oral Tab [FMC],2581916,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,260,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.36,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,10.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,12.976,percent of total billed charges,40% of total billed charges,0.96,2.55,
vitamin D 1000 intl units oral Tab [FMC],2581916,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,260,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.696,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,10.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,13.392,percent of total billed charges,40% of total billed charges,0.96,2.55,
polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [FMC],2581924,CDM,250,RC,,,OUTPATIENT,4000,ML,93.6,56.16,,79.56,85,,63.648,Percent of total billed charges,85% of total billed charges,46.8,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,46.8,50,,2,percent of total billed charges,50% of total billed charges,29.91,31.95,,10.696,percent of total billed charges,31.95% of total billed charges,29.91,31.95,,10.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.57,38,,28.456,percent of total billed charges,38% of total billed charges,37.44,40,,13.392,percent of total billed charges,40% of total billed charges,29.91,79.56,
polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [FMC],2581924,CDM,250,RC,,,OUTPATIENT,4000,ML,92.56,55.536,,78.68,85,,62.944,Percent of total billed charges,85% of total billed charges,46.28,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,46.28,50,,7.648,percent of total billed charges,50% of total billed charges,29.57,31.95,,12.696,percent of total billed charges,31.95% of total billed charges,29.57,31.95,,12.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.17,38,,28.136,percent of total billed charges,38% of total billed charges,37.02,40,,15.888,percent of total billed charges,40% of total billed charges,29.57,78.68,
polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [FMC],2581924,CDM,250,RC,,,OUTPATIENT,4000,ML,100.75,60.45,,85.64,85,,68.512,Percent of total billed charges,85% of total billed charges,50.38,50,,7.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.38,50,,5.504,percent of total billed charges,50% of total billed charges,32.19,31.95,,20.616,percent of total billed charges,31.95% of total billed charges,32.19,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.29,38,,30.632,percent of total billed charges,38% of total billed charges,40.3,40,,18.744,percent of total billed charges,40% of total billed charges,32.19,85.64,
calcitonin 200 intl units/mL Inj Sol [FMC],2581932,CDM,250,RC,J0630,HCPCS,OUTPATIENT,2,ML,7177.3,4306.38,,6100.71,85,,4880.568,Percent of total billed charges,85% of total billed charges,1947.92,136.6,,5.504,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1947.92,136.6,,47.2,fee schedule,136.60% of BCBS custom fee schedule,2522.82,35.15,,14.624,percent of total billed charges,35.15% of total billed charges,62.08,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2727.37,38,,2181.896,percent of total billed charges,38% of total billed charges,2293.15,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,62.08,6100.71,
calcitonin 200 intl units/mL Inj Sol [FMC],2581932,CDM,250,RC,J0630,HCPCS,OUTPATIENT,2,ML,12215.19,7329.114,,10382.91,85,,8306.328,Percent of total billed charges,85% of total billed charges,1947.92,136.6,,47.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1947.92,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,4293.64,35.15,,22.88,percent of total billed charges,35.15% of total billed charges,62.08,31.95,,22.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4641.77,38,,3713.416,percent of total billed charges,38% of total billed charges,3902.75,31.95,,28.64,percent of total billed charges,31.95% of total billed charges,62.08,10382.91,
Dextrose 5% with NS and KCl 20 mEq/l IV Sol 1000 mL [FMC],2581973,CDM,250,RC,,,OUTPATIENT,1000,ML,38.06,22.836,,32.35,85,,25.88,Percent of total billed charges,85% of total billed charges,19.03,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.03,50,,26.672,percent of total billed charges,50% of total billed charges,12.16,31.95,,9.752,percent of total billed charges,31.95% of total billed charges,12.16,31.95,,9.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.46,38,,11.568,percent of total billed charges,38% of total billed charges,15.22,40,,12.208,percent of total billed charges,40% of total billed charges,12.16,32.35,
Dextrose 5% with NS and KCl 20 mEq/l IV Sol 1000 mL [FMC],2581973,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,26.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,5.6,percent of total billed charges,50% of total billed charges,11.5,31.95,,400.472,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,364.008,percent of total billed charges,40% of total billed charges,11.5,30.6,
isoproterenol 0.2 mg/mL IV Sol [FMC],2581981,CDM,250,RC,,,OUTPATIENT,5,ML,663,397.8,,563.55,85,,450.84,Percent of total billed charges,85% of total billed charges,331.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,331.5,50,,168.056,percent of total billed charges,50% of total billed charges,211.83,31.95,,223.472,percent of total billed charges,31.95% of total billed charges,211.83,31.95,,223.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,251.94,38,,201.552,percent of total billed charges,38% of total billed charges,265.2,40,,279.776,percent of total billed charges,40% of total billed charges,211.83,563.55,
isoproterenol 0.2 mg/mL IV Sol [FMC],2581981,CDM,250,RC,,,OUTPATIENT,5,ML,2125.5,1275.3,,1806.68,85,,1445.344,Percent of total billed charges,85% of total billed charges,1062.75,50,,168.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1062.75,50,,6,percent of total billed charges,50% of total billed charges,679.1,31.95,,232.784,percent of total billed charges,31.95% of total billed charges,679.1,31.95,,232.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,807.69,38,,646.152,percent of total billed charges,38% of total billed charges,850.2,40,,291.44,percent of total billed charges,40% of total billed charges,679.1,1806.68,
cholecalciferol 2000 intl units Tab [FMC],2582005,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,168.056,percent of total billed charges,50% of total billed charges,0.96,31.95,,248.304,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,248.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,310.864,percent of total billed charges,40% of total billed charges,0.96,2.55,
cholecalciferol 2000 intl units Tab [FMC],2582005,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,168.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,135,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
flax oral 1000 mg capsule [FMC],2582021,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,135,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,21.288,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,3.576,percent of total billed charges,40% of total billed charges,0.96,2.55,
flax oral 1000 mg capsule [FMC],2582021,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,21.288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,80,percent of total billed charges,50% of total billed charges,0.96,31.95,,23.368,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,21.24,percent of total billed charges,40% of total billed charges,0.96,2.55,
fenofibric acid 135 mg ER UD [FMC],2582112,CDM,250,RC,,,OUTPATIENT,1,EA,19.48,11.688,,16.56,85,,13.248,Percent of total billed charges,85% of total billed charges,9.74,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.74,50,,4.008,percent of total billed charges,50% of total billed charges,6.22,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,6.22,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.4,38,,5.92,percent of total billed charges,38% of total billed charges,7.79,40,,13.008,percent of total billed charges,40% of total billed charges,6.22,16.56,
fenofibric acid 135 mg ER UD [FMC],2582112,CDM,250,RC,,,OUTPATIENT,1,EA,19.48,11.688,,16.56,85,,13.248,Percent of total billed charges,85% of total billed charges,9.74,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.74,50,,4.008,percent of total billed charges,50% of total billed charges,6.22,31.95,,16.56,percent of total billed charges,31.95% of total billed charges,6.22,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.4,38,,5.92,percent of total billed charges,38% of total billed charges,7.79,40,,15.056,percent of total billed charges,40% of total billed charges,6.22,16.56,
fenofibric acid 135 mg ER UD [FMC],2582112,CDM,250,RC,,,OUTPATIENT,1,EA,19.48,11.688,,16.56,85,,13.248,Percent of total billed charges,85% of total billed charges,9.74,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.74,50,,4.008,percent of total billed charges,50% of total billed charges,6.22,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,6.22,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.4,38,,5.92,percent of total billed charges,38% of total billed charges,7.79,40,,13.008,percent of total billed charges,40% of total billed charges,6.22,16.56,
fenofibric acid 135 mg ER UD [FMC],2582112,CDM,250,RC,,,OUTPATIENT,1,EA,19.49,11.694,,16.57,85,,13.256,Percent of total billed charges,85% of total billed charges,9.75,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.75,50,,4.008,percent of total billed charges,50% of total billed charges,6.23,31.95,,8.92,percent of total billed charges,31.95% of total billed charges,6.23,31.95,,8.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.41,38,,5.928,percent of total billed charges,38% of total billed charges,7.8,40,,11.168,percent of total billed charges,40% of total billed charges,6.23,16.57,
fenofibric acid 135 mg ER UD [FMC],2582112,CDM,250,RC,,,OUTPATIENT,1,EA,3.25,1.95,,2.76,85,,2.208,Percent of total billed charges,85% of total billed charges,1.63,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.63,50,,4.008,percent of total billed charges,50% of total billed charges,1.04,31.95,,8.92,percent of total billed charges,31.95% of total billed charges,1.04,31.95,,8.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.24,38,,0.992,percent of total billed charges,38% of total billed charges,1.3,40,,11.168,percent of total billed charges,40% of total billed charges,1.04,2.76,
fenofibric acid 135 mg ER UD [FMC],2582112,CDM,250,RC,,,OUTPATIENT,1,EA,17.34,10.404,,14.74,85,,11.792,Percent of total billed charges,85% of total billed charges,8.67,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.67,50,,4.008,percent of total billed charges,50% of total billed charges,5.54,31.95,,20.512,percent of total billed charges,31.95% of total billed charges,5.54,31.95,,20.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.59,38,,5.272,percent of total billed charges,38% of total billed charges,6.94,40,,25.68,percent of total billed charges,40% of total billed charges,5.54,14.74,
candesartan 8 mg Tab [FMC],2582146,CDM,250,RC,,,OUTPATIENT,1,EA,11.46,6.876,,9.74,85,,7.792,Percent of total billed charges,85% of total billed charges,5.73,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.73,50,,94.4,percent of total billed charges,50% of total billed charges,3.66,31.95,,16.688,percent of total billed charges,31.95% of total billed charges,3.66,31.95,,16.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.35,38,,3.48,percent of total billed charges,38% of total billed charges,4.58,40,,20.896,percent of total billed charges,40% of total billed charges,3.66,9.74,
candesartan 8 mg Tab [FMC],2582146,CDM,250,RC,,,OUTPATIENT,1,EA,15.45,9.27,,13.13,85,,10.504,Percent of total billed charges,85% of total billed charges,7.73,50,,94.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.73,50,,18.8,percent of total billed charges,50% of total billed charges,4.94,31.95,,16.784,percent of total billed charges,31.95% of total billed charges,4.94,31.95,,16.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.87,38,,4.696,percent of total billed charges,38% of total billed charges,6.18,40,,21.008,percent of total billed charges,40% of total billed charges,4.94,13.13,
candesartan 8 mg Tab [FMC],2582146,CDM,250,RC,,,OUTPATIENT,1,EA,10.31,6.186,,8.76,85,,7.008,Percent of total billed charges,85% of total billed charges,5.16,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.16,50,,18.8,percent of total billed charges,50% of total billed charges,3.29,31.95,,16,percent of total billed charges,31.95% of total billed charges,3.29,31.95,,16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.92,38,,3.136,percent of total billed charges,38% of total billed charges,4.12,40,,20.032,percent of total billed charges,40% of total billed charges,3.29,8.76,
candesartan 8 mg Tab [FMC],2582146,CDM,250,RC,,,OUTPATIENT,1,EA,9.93,5.958,,8.44,85,,6.752,Percent of total billed charges,85% of total billed charges,4.97,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.97,50,,18.8,percent of total billed charges,50% of total billed charges,3.17,31.95,,16.784,percent of total billed charges,31.95% of total billed charges,3.17,31.95,,16.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.77,38,,3.016,percent of total billed charges,38% of total billed charges,3.97,40,,21.008,percent of total billed charges,40% of total billed charges,3.17,8.44,
candesartan 8 mg Tab [FMC],2582146,CDM,250,RC,,,OUTPATIENT,1,EA,9.93,5.958,,8.44,85,,6.752,Percent of total billed charges,85% of total billed charges,4.97,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.97,50,,13.2,percent of total billed charges,50% of total billed charges,3.17,31.95,,4.424,percent of total billed charges,31.95% of total billed charges,3.17,31.95,,4.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.77,38,,3.016,percent of total billed charges,38% of total billed charges,3.97,40,,5.536,percent of total billed charges,40% of total billed charges,3.17,8.44,
cisatracurium 2 mg/mL IV Sol [FMC],2582179,CDM,250,RC,,,OUTPATIENT,10,ML,94.09,56.454,,79.98,85,,63.984,Percent of total billed charges,85% of total billed charges,47.05,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47.05,50,,18.8,percent of total billed charges,50% of total billed charges,30.06,31.95,,6.168,percent of total billed charges,31.95% of total billed charges,30.06,31.95,,6.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.75,38,,28.6,percent of total billed charges,38% of total billed charges,37.64,40,,7.72,percent of total billed charges,40% of total billed charges,30.06,79.98,
cisatracurium 2 mg/mL IV Sol [FMC],2582179,CDM,250,RC,,,OUTPATIENT,10,ML,89.7,53.82,,76.25,85,,61,Percent of total billed charges,85% of total billed charges,44.85,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.85,50,,33.6,percent of total billed charges,50% of total billed charges,28.66,31.95,,3.952,percent of total billed charges,31.95% of total billed charges,28.66,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.09,38,,27.272,percent of total billed charges,38% of total billed charges,35.88,40,,3.592,percent of total billed charges,40% of total billed charges,28.66,76.25,
cisatracurium 2 mg/mL IV Sol [FMC],2582179,CDM,250,RC,,,OUTPATIENT,10,ML,89.7,53.82,,76.25,85,,61,Percent of total billed charges,85% of total billed charges,44.85,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.85,50,,486,percent of total billed charges,50% of total billed charges,28.66,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,28.66,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.09,38,,27.272,percent of total billed charges,38% of total billed charges,35.88,40,,3.576,percent of total billed charges,40% of total billed charges,28.66,76.25,
cefOXitin 1 g Inj [FMC],2582187,CDM,250,RC,J0694,HCPCS,OUTPATIENT,1,EA,24.88,14.928,,21.15,85,,16.92,Percent of total billed charges,85% of total billed charges,7.77,136.6,,486,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.77,136.6,,26.4,fee schedule,136.60% of BCBS custom fee schedule,8.75,35.15,,45.144,fee schedule,35.15% of LA custom fee schedule,7.95,31.95,,45.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.45,38,,7.56,percent of total billed charges,38% of total billed charges,7.95,31.95,,56.512,Fee Schedule,31.95% of LA custom fee schedule,7.77,21.15,
cefOXitin 1 g Inj [FMC],2582187,CDM,250,RC,J0694,HCPCS,OUTPATIENT,1,EA,38.81,23.286,,32.99,85,,26.392,Percent of total billed charges,85% of total billed charges,7.77,136.6,,26.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.77,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,13.64,35.15,,34.76,fee schedule,35.15% of LA custom fee schedule,12.4,31.95,,34.76,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.75,38,,11.8,percent of total billed charges,38% of total billed charges,12.4,31.95,,43.512,Fee Schedule,31.95% of LA custom fee schedule,7.77,32.99,
cefOXitin 1 g Inj [FMC],2582187,CDM,250,RC,J0694,HCPCS,OUTPATIENT,1,EA,36.48,21.888,,31.01,85,,24.808,Percent of total billed charges,85% of total billed charges,7.77,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.77,136.6,,405,fee schedule,136.60% of BCBS custom fee schedule,12.82,35.15,,29.072,fee schedule,35.15% of LA custom fee schedule,11.66,31.95,,29.072,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.86,38,,11.088,percent of total billed charges,38% of total billed charges,11.66,31.95,,36.4,Fee Schedule,31.95% of LA custom fee schedule,7.77,31.01,
fenofibric acid 45 mg ER UD [FMC],2582203,CDM,250,RC,,,OUTPATIENT,1,EA,6.49,3.894,,5.52,85,,4.416,Percent of total billed charges,85% of total billed charges,3.25,50,,405,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,3.12,percent of total billed charges,50% of total billed charges,2.07,31.95,,208.368,percent of total billed charges,31.95% of total billed charges,2.07,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,189.4,percent of total billed charges,40% of total billed charges,2.07,5.52,
fenofibric acid 45 mg ER UD [FMC],2582203,CDM,250,RC,,,OUTPATIENT,1,EA,6.49,3.894,,5.52,85,,4.416,Percent of total billed charges,85% of total billed charges,3.25,50,,3.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,3.312,percent of total billed charges,50% of total billed charges,2.07,31.95,,11.512,percent of total billed charges,31.95% of total billed charges,2.07,31.95,,11.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,14.416,percent of total billed charges,40% of total billed charges,2.07,5.52,
fenofibric acid 45 mg ER UD [FMC],2582203,CDM,250,RC,,,OUTPATIENT,1,EA,10.97,6.582,,9.32,85,,7.456,Percent of total billed charges,85% of total billed charges,5.49,50,,3.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.49,50,,192,percent of total billed charges,50% of total billed charges,3.5,31.95,,11.584,percent of total billed charges,31.95% of total billed charges,3.5,31.95,,11.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.17,38,,3.336,percent of total billed charges,38% of total billed charges,4.39,40,,14.504,percent of total billed charges,40% of total billed charges,3.5,9.32,
fenofibric acid 45 mg ER UD [FMC],2582203,CDM,250,RC,,,OUTPATIENT,1,EA,6.5,3.9,,5.53,85,,4.424,Percent of total billed charges,85% of total billed charges,3.25,50,,192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,16,percent of total billed charges,50% of total billed charges,2.08,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,2.08,31.95,,2.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,2.6,percent of total billed charges,40% of total billed charges,2.08,5.53,
fenofibric acid 45 mg ER UD [FMC],2582203,CDM,250,RC,,,OUTPATIENT,1,EA,6.49,3.894,,5.52,85,,4.416,Percent of total billed charges,85% of total billed charges,3.25,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.25,50,,32,percent of total billed charges,50% of total billed charges,2.07,31.95,,3.28,percent of total billed charges,31.95% of total billed charges,2.07,31.95,,3.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.47,38,,1.976,percent of total billed charges,38% of total billed charges,2.6,40,,4.112,percent of total billed charges,40% of total billed charges,2.07,5.52,
etomidate 2 mg/mL IV Sol [FMC],2582229,CDM,250,RC,J1885,HCPCS,OUTPATIENT,10,ML,22.01,13.206,,18.71,85,,14.968,Percent of total billed charges,85% of total billed charges,0.92,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,7.74,35.15,,38.128,percent of total billed charges,35.15% of total billed charges,62.08,31.95,,38.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,6.688,percent of total billed charges,38% of total billed charges,7.03,31.95,,47.736,percent of total billed charges,31.95% of total billed charges,0.92,62.08,
etomidate 2 mg/mL IV Sol [FMC],2582229,CDM,250,RC,J1885,HCPCS,OUTPATIENT,10,ML,25.63,15.378,,21.79,85,,17.432,Percent of total billed charges,85% of total billed charges,0.92,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,9.01,35.15,,2.992,percent of total billed charges,35.15% of total billed charges,63.31,31.95,,2.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.74,38,,7.792,percent of total billed charges,38% of total billed charges,8.19,31.95,,3.744,percent of total billed charges,31.95% of total billed charges,0.92,63.31,
etomidate 2 mg/mL IV Sol [FMC],2582229,CDM,250,RC,J1885,HCPCS,OUTPATIENT,10,ML,24.26,14.556,,20.62,85,,16.496,Percent of total billed charges,85% of total billed charges,0.92,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,49.456,fee schedule,136.60% of BCBS custom fee schedule,8.53,35.15,,41.024,percent of total billed charges,35.15% of total billed charges,63.31,31.95,,41.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.22,38,,7.376,percent of total billed charges,38% of total billed charges,7.75,31.95,,51.36,percent of total billed charges,31.95% of total billed charges,0.92,63.31,
etomidate 2 mg/mL IV Sol [FMC],2582229,CDM,250,RC,J1885,HCPCS,OUTPATIENT,10,ML,38.26,22.956,,32.52,85,,26.016,Percent of total billed charges,85% of total billed charges,0.92,136.6,,49.456,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,22.784,fee schedule,136.60% of BCBS custom fee schedule,13.45,35.15,,29.072,percent of total billed charges,35.15% of total billed charges,63.31,31.95,,29.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.54,38,,11.632,percent of total billed charges,38% of total billed charges,12.22,31.95,,36.4,percent of total billed charges,31.95% of total billed charges,0.92,63.31,
etomidate 2 mg/mL IV Sol [FMC],2582229,CDM,250,RC,J1885,HCPCS,OUTPATIENT,10,ML,21.45,12.87,,18.23,85,,14.584,Percent of total billed charges,85% of total billed charges,0.92,136.6,,22.784,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,217.352,fee schedule,136.60% of BCBS custom fee schedule,7.54,35.15,,0.832,percent of total billed charges,35.15% of total billed charges,63.31,31.95,,0.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.15,38,,6.52,percent of total billed charges,38% of total billed charges,6.85,31.95,,1.04,percent of total billed charges,31.95% of total billed charges,0.92,63.31,
etomidate 2 mg/mL IV Sol [FMC],2582229,CDM,250,RC,J1885,HCPCS,OUTPATIENT,10,ML,25.63,15.378,,21.79,85,,17.432,Percent of total billed charges,85% of total billed charges,0.92,136.6,,217.352,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,9.01,35.15,,1.176,percent of total billed charges,35.15% of total billed charges,63.36,31.95,,1.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.74,38,,7.792,percent of total billed charges,38% of total billed charges,8.19,31.95,,1.472,percent of total billed charges,31.95% of total billed charges,0.92,63.36,
etomidate 2 mg/mL IV Sol [FMC],2582229,CDM,250,RC,J1885,HCPCS,OUTPATIENT,10,ML,31.2,18.72,,26.52,85,,21.216,Percent of total billed charges,85% of total billed charges,0.92,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,35.2,fee schedule,136.60% of BCBS custom fee schedule,10.97,35.15,,0.84,percent of total billed charges,35.15% of total billed charges,657.85,31.95,,0.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.86,38,,9.488,percent of total billed charges,38% of total billed charges,9.97,31.95,,1.048,percent of total billed charges,31.95% of total billed charges,0.92,657.85,
valACYclovir 500 mg Tab [FMC],2582252,CDM,250,RC,,,OUTPATIENT,1,EA,23.48,14.088,,19.96,85,,15.968,Percent of total billed charges,85% of total billed charges,11.74,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.74,50,,35.2,percent of total billed charges,50% of total billed charges,7.5,31.95,,659.104,percent of total billed charges,31.95% of total billed charges,7.5,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.92,38,,7.136,percent of total billed charges,38% of total billed charges,9.39,40,,599.104,percent of total billed charges,40% of total billed charges,7.5,19.96,
valACYclovir 500 mg Tab [FMC],2582252,CDM,250,RC,,,OUTPATIENT,1,EA,9.5,5.7,,8.08,85,,6.464,Percent of total billed charges,85% of total billed charges,4.75,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.75,50,,33.6,percent of total billed charges,50% of total billed charges,3.04,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,3.04,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.61,38,,2.888,percent of total billed charges,38% of total billed charges,3.8,40,,3.064,percent of total billed charges,40% of total billed charges,3.04,8.08,
estradiol topical 10 mcg Tab [FMC],2582260,CDM,250,RC,,,OUTPATIENT,1,EA,55.3,33.18,,47.01,85,,37.608,Percent of total billed charges,85% of total billed charges,27.65,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.65,50,,33.6,percent of total billed charges,50% of total billed charges,17.67,31.95,,3.984,percent of total billed charges,31.95% of total billed charges,17.67,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.01,38,,16.808,percent of total billed charges,38% of total billed charges,22.12,40,,3.616,percent of total billed charges,40% of total billed charges,17.67,47.01,
estradiol topical 10 mcg Tab [FMC],2582260,CDM,250,RC,,,OUTPATIENT,1,EA,82.95,49.77,,70.51,85,,56.408,Percent of total billed charges,85% of total billed charges,41.48,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,41.48,50,,11.704,percent of total billed charges,50% of total billed charges,26.5,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,26.5,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.52,38,,25.216,percent of total billed charges,38% of total billed charges,33.18,40,,3.064,percent of total billed charges,40% of total billed charges,26.5,70.51,
insulin aspart-insulin aspart protamine 70 units-30 units/mL SubQ Susp 10 mL [FMC],2582278,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,117.05,70.23,,99.49,85,,79.592,Percent of total billed charges,85% of total billed charges,0.76,136.6,,11.704,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,41.14,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,37.4,31.95,,6.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,44.48,38,,35.584,percent of total billed charges,38% of total billed charges,37.4,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,0.76,99.49,
insulin aspart-insulin aspart protamine 70 units-30 units/mL SubQ Susp 10 mL [FMC],2582278,CDM,250,RC,J1815,HCPCS,OUTPATIENT,1,ML,58.52,35.112,,49.74,85,,39.792,Percent of total billed charges,85% of total billed charges,0.76,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,20.57,35.15,,3391.704,fee schedule,35.15% of LA custom fee schedule,18.7,31.95,,3391.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.24,38,,17.792,percent of total billed charges,38% of total billed charges,18.7,31.95,,4246.272,Fee Schedule,31.95% of LA custom fee schedule,0.76,49.74,
diltiazem 5 mg/mL IV 10mL Sol [FMC],2582286,CDM,250,RC,,,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,12.976,percent of total billed charges,50% of total billed charges,3.83,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,6.232,percent of total billed charges,40% of total billed charges,3.83,10.2,
diltiazem 5 mg/mL IV 10mL Sol [FMC],2582286,CDM,250,RC,,,OUTPATIENT,10,ML,24.29,14.574,,20.65,85,,16.52,Percent of total billed charges,85% of total billed charges,12.15,50,,12.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.15,50,,29.376,percent of total billed charges,50% of total billed charges,7.76,31.95,,5.072,percent of total billed charges,31.95% of total billed charges,7.76,31.95,,5.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.23,38,,7.384,percent of total billed charges,38% of total billed charges,9.72,40,,6.352,percent of total billed charges,40% of total billed charges,7.76,20.65,
diltiazem 5 mg/mL IV 10mL Sol [FMC],2582286,CDM,250,RC,,,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,29.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,2.888,percent of total billed charges,50% of total billed charges,3.83,31.95,,12.368,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,12.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,15.488,percent of total billed charges,40% of total billed charges,3.83,10.2,
diltiazem 5 mg/mL IV 10mL Sol [FMC],2582286,CDM,250,RC,,,OUTPATIENT,10,ML,12.36,7.416,,10.51,85,,8.408,Percent of total billed charges,85% of total billed charges,6.18,50,,2.888,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.18,50,,41.2,percent of total billed charges,50% of total billed charges,3.95,31.95,,19.616,percent of total billed charges,31.95% of total billed charges,3.95,31.95,,19.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.7,38,,3.76,percent of total billed charges,38% of total billed charges,4.94,40,,24.552,percent of total billed charges,40% of total billed charges,3.95,10.51,
diltiazem 5 mg/mL IV 10mL Sol [FMC],2582286,CDM,250,RC,,,OUTPATIENT,10,ML,15.21,9.126,,12.93,85,,10.344,Percent of total billed charges,85% of total billed charges,7.61,50,,41.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.61,50,,8,percent of total billed charges,50% of total billed charges,4.86,31.95,,25.832,percent of total billed charges,31.95% of total billed charges,4.86,31.95,,25.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.78,38,,4.624,percent of total billed charges,38% of total billed charges,6.08,40,,32.344,percent of total billed charges,40% of total billed charges,4.86,12.93,
diltiazem 5 mg/mL IV 10mL Sol [FMC],2582286,CDM,250,RC,,,OUTPATIENT,10,ML,26.83,16.098,,22.81,85,,18.248,Percent of total billed charges,85% of total billed charges,13.42,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.42,50,,6.352,percent of total billed charges,50% of total billed charges,8.57,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,8.57,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.2,38,,8.16,percent of total billed charges,38% of total billed charges,10.73,40,,3.84,percent of total billed charges,40% of total billed charges,8.57,22.81,
cephalexin 125 mg/5 mL Oral Liq [FMC],2582294,CDM,250,RC,,,OUTPATIENT,100,ML,67.31,40.386,,57.21,85,,45.768,Percent of total billed charges,85% of total billed charges,33.66,50,,6.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.66,50,,12.056,percent of total billed charges,50% of total billed charges,21.51,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,21.51,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.58,38,,20.464,percent of total billed charges,38% of total billed charges,26.92,40,,3.84,percent of total billed charges,40% of total billed charges,21.51,57.21,
cephalexin 125 mg/5 mL Oral Liq [FMC],2582294,CDM,250,RC,,,OUTPATIENT,100,ML,76.21,45.726,,64.78,85,,51.824,Percent of total billed charges,85% of total billed charges,38.11,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38.11,50,,12.056,percent of total billed charges,50% of total billed charges,24.35,31.95,,3.408,percent of total billed charges,31.95% of total billed charges,24.35,31.95,,3.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.96,38,,23.168,percent of total billed charges,38% of total billed charges,30.48,40,,4.272,percent of total billed charges,40% of total billed charges,24.35,64.78,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,8.968,percent of total billed charges,35.15% of total billed charges,670.95,31.95,,8.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,11.232,percent of total billed charges,31.95% of total billed charges,0.23,670.95,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,8.528,percent of total billed charges,35.15% of total billed charges,670.95,31.95,,8.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,10.68,percent of total billed charges,31.95% of total billed charges,0.23,670.95,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.808,percent of total billed charges,35.15% of total billed charges,670.95,31.95,,4.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,6.024,percent of total billed charges,31.95% of total billed charges,0.23,670.95,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.64,percent of total billed charges,35.15% of total billed charges,670.95,31.95,,4.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,5.808,percent of total billed charges,31.95% of total billed charges,0.23,670.95,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,4.688,percent of total billed charges,35.15% of total billed charges,670.95,31.95,,4.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,5.864,percent of total billed charges,31.95% of total billed charges,0.23,670.95,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,12.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,184.8,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,8.72,percent of total billed charges,35.15% of total billed charges,681.17,31.95,,8.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,10.92,percent of total billed charges,31.95% of total billed charges,0.23,681.17,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,184.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,1.664,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,6.392,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,8,percent of total billed charges,31.95% of total billed charges,0.23,694.91,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,1.664,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,3.584,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,9.888,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,9.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,12.376,percent of total billed charges,31.95% of total billed charges,0.23,694.91,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,3.584,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,142.872,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,5.752,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,5.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,7.2,percent of total billed charges,31.95% of total billed charges,0.23,694.91,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,142.872,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,21.936,percent of total billed charges,35.15% of total billed charges,702.9,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,0.23,702.9,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,38.96,percent of total billed charges,35.15% of total billed charges,720.47,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,35.416,percent of total billed charges,31.95% of total billed charges,0.23,720.47,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,33.904,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,40.584,percent of total billed charges,35.15% of total billed charges,720.79,31.95,,64.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,36.888,percent of total billed charges,31.95% of total billed charges,0.23,720.79,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,33.904,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,2.416,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,41.128,percent of total billed charges,35.15% of total billed charges,734.85,31.95,,64.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,37.384,percent of total billed charges,31.95% of total billed charges,0.23,734.85,
albuterol-ipratropium Inh Sol 3 mL [FMC],2582344,CDM,250,RC,J7620,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,2.416,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,51.48,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,40.584,percent of total billed charges,35.15% of total billed charges,734.85,31.95,,64.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,36.888,percent of total billed charges,31.95% of total billed charges,0.23,734.85,
Coenzyme Q-10 30mg Cap [FMC],2582377,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,51.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,67.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,10.12,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,65.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,9.2,percent of total billed charges,40% of total billed charges,0.96,2.55,
Coenzyme Q-10 30mg Cap [FMC],2582377,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.144,percent of total billed charges,50% of total billed charges,0.96,31.95,,3.584,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,4.48,percent of total billed charges,40% of total billed charges,0.96,2.55,
roflumilast 500 mcg Tab [FMC],2582401,CDM,250,RC,,,OUTPATIENT,1,EA,30.5,18.3,,25.93,85,,20.744,Percent of total billed charges,85% of total billed charges,15.25,50,,3.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.25,50,,71.8,percent of total billed charges,50% of total billed charges,9.74,31.95,,372.792,percent of total billed charges,31.95% of total billed charges,9.74,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.59,38,,9.272,percent of total billed charges,38% of total billed charges,12.2,40,,338.856,percent of total billed charges,40% of total billed charges,9.74,25.93,
roflumilast 500 mcg Tab [FMC],2582401,CDM,250,RC,,,OUTPATIENT,1,EA,33.52,20.112,,28.49,85,,22.792,Percent of total billed charges,85% of total billed charges,16.76,50,,71.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.76,50,,17.056,percent of total billed charges,50% of total billed charges,10.71,31.95,,115.152,percent of total billed charges,31.95% of total billed charges,10.71,31.95,,67.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.74,38,,10.192,percent of total billed charges,38% of total billed charges,13.41,40,,104.672,percent of total billed charges,40% of total billed charges,10.71,28.49,
roflumilast 500 mcg Tab [FMC],2582401,CDM,250,RC,,,OUTPATIENT,1,EA,38.36,23.016,,32.61,85,,26.088,Percent of total billed charges,85% of total billed charges,19.18,50,,17.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.18,50,,3.144,percent of total billed charges,50% of total billed charges,12.26,31.95,,488.56,percent of total billed charges,31.95% of total billed charges,12.26,31.95,,67.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.58,38,,11.664,percent of total billed charges,38% of total billed charges,15.34,40,,444.088,percent of total billed charges,40% of total billed charges,12.26,32.61,
roflumilast 500 mcg Tab [FMC],2582401,CDM,250,RC,,,OUTPATIENT,1,EA,48.94,29.364,,41.6,85,,33.28,Percent of total billed charges,85% of total billed charges,24.47,50,,3.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.47,50,,2.4,percent of total billed charges,50% of total billed charges,15.64,31.95,,86.64,percent of total billed charges,31.95% of total billed charges,15.64,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.6,38,,14.88,percent of total billed charges,38% of total billed charges,19.58,40,,78.752,percent of total billed charges,40% of total billed charges,15.64,41.6,
roflumilast 500 mcg Tab [FMC],2582401,CDM,250,RC,,,OUTPATIENT,1,EA,48.95,29.37,,41.61,85,,33.288,Percent of total billed charges,85% of total billed charges,24.48,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.48,50,,168,percent of total billed charges,50% of total billed charges,15.64,31.95,,65.8,percent of total billed charges,31.95% of total billed charges,15.64,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.6,38,,14.88,percent of total billed charges,38% of total billed charges,19.58,40,,59.808,percent of total billed charges,40% of total billed charges,15.64,41.61,
"thrombin topical bovine 20,000 intl units REC [FMC]",2582419,CDM,250,RC,,,OUTPATIENT,1,EA,1053.71,632.226,,895.65,85,,716.52,Percent of total billed charges,85% of total billed charges,526.86,50,,168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,526.86,50,,117.832,percent of total billed charges,50% of total billed charges,336.66,31.95,,65.8,percent of total billed charges,31.95% of total billed charges,336.66,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,400.41,38,,320.328,percent of total billed charges,38% of total billed charges,421.48,40,,59.808,percent of total billed charges,40% of total billed charges,336.66,895.65,
moisturizing lotion [FMC],2582468,CDM,250,RC,,,OUTPATIENT,1,EA,24.9,14.94,,21.17,85,,16.936,Percent of total billed charges,85% of total billed charges,12.45,50,,117.832,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.45,50,,63.504,percent of total billed charges,50% of total billed charges,7.96,31.95,,32.904,percent of total billed charges,31.95% of total billed charges,7.96,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.46,38,,7.568,percent of total billed charges,38% of total billed charges,9.96,40,,29.904,percent of total billed charges,40% of total billed charges,7.96,21.17,
dabigatran 75 mg Cap [FMC],2582492,CDM,250,RC,,,OUTPATIENT,1,EA,25.56,15.336,,21.73,85,,17.384,Percent of total billed charges,85% of total billed charges,12.78,50,,63.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.78,50,,5,percent of total billed charges,50% of total billed charges,8.17,31.95,,32.848,percent of total billed charges,31.95% of total billed charges,8.17,31.95,,32.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.71,38,,7.768,percent of total billed charges,38% of total billed charges,10.22,40,,41.12,percent of total billed charges,40% of total billed charges,8.17,21.73,
dabigatran 75 mg Cap [FMC],2582492,CDM,250,RC,,,OUTPATIENT,1,EA,23.67,14.202,,20.12,85,,16.096,Percent of total billed charges,85% of total billed charges,11.84,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.84,50,,5,percent of total billed charges,50% of total billed charges,7.56,31.95,,32.848,percent of total billed charges,31.95% of total billed charges,7.56,31.95,,32.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.99,38,,7.192,percent of total billed charges,38% of total billed charges,9.47,40,,41.12,percent of total billed charges,40% of total billed charges,7.56,20.12,
dabigatran 75 mg Cap [FMC],2582492,CDM,250,RC,,,OUTPATIENT,1,EA,32.24,19.344,,27.4,85,,21.92,Percent of total billed charges,85% of total billed charges,16.12,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.12,50,,47.864,percent of total billed charges,50% of total billed charges,10.3,31.95,,32.896,percent of total billed charges,31.95% of total billed charges,10.3,31.95,,32.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.25,38,,9.8,percent of total billed charges,38% of total billed charges,12.9,40,,41.184,percent of total billed charges,40% of total billed charges,10.3,27.4,
dabigatran 75 mg Cap [FMC],2582492,CDM,250,RC,,,OUTPATIENT,1,EA,12.25,7.35,,10.41,85,,8.328,Percent of total billed charges,85% of total billed charges,6.13,50,,47.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.13,50,,2.864,percent of total billed charges,50% of total billed charges,3.91,31.95,,1422.656,percent of total billed charges,31.95% of total billed charges,3.91,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.66,38,,3.728,percent of total billed charges,38% of total billed charges,4.9,40,,1293.144,percent of total billed charges,40% of total billed charges,3.91,10.41,
emtricitabine-tenofovir 200 mg-300 mg Tab [FMC],2582534,CDM,250,RC,,,OUTPATIENT,1,EA,239.5,143.7,,203.58,85,,162.864,Percent of total billed charges,85% of total billed charges,119.75,50,,2.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,119.75,50,,226,percent of total billed charges,50% of total billed charges,76.52,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,76.52,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,91.01,38,,72.808,percent of total billed charges,38% of total billed charges,95.8,40,,0.96,percent of total billed charges,40% of total billed charges,76.52,203.58,
emtricitabine-tenofovir 200 mg-300 mg Tab [FMC],2582534,CDM,250,RC,,,OUTPATIENT,1,EA,227.52,136.512,,193.39,85,,154.712,Percent of total billed charges,85% of total billed charges,113.76,50,,226,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,113.76,50,,298,percent of total billed charges,50% of total billed charges,72.69,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,72.69,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,86.46,38,,69.168,percent of total billed charges,38% of total billed charges,91.01,40,,0.96,percent of total billed charges,40% of total billed charges,72.69,193.39,
levETIRAcetam 100 mg/mL Sol [FMC],2582591,CDM,250,RC,J1953,HCPCS,OUTPATIENT,5,ML,182.14,109.284,,154.82,85,,123.856,Percent of total billed charges,85% of total billed charges,0.11,136.6,,298,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,19.6,fee schedule,136.60% of BCBS custom fee schedule,64.02,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,744.12,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.21,38,,55.368,percent of total billed charges,38% of total billed charges,58.19,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,0.11,744.12,
levETIRAcetam 100 mg/mL Sol [FMC],2582591,CDM,250,RC,J1953,HCPCS,OUTPATIENT,5,ML,12.19,7.314,,10.36,85,,8.288,Percent of total billed charges,85% of total billed charges,0.11,136.6,,19.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,31.6,fee schedule,136.60% of BCBS custom fee schedule,4.28,35.15,,524.216,percent of total billed charges,35.15% of total billed charges,803.22,31.95,,7.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.63,38,,3.704,percent of total billed charges,38% of total billed charges,3.89,31.95,,476.488,percent of total billed charges,31.95% of total billed charges,0.11,803.22,
levETIRAcetam 100 mg/mL Sol [FMC],2582591,CDM,250,RC,J1953,HCPCS,OUTPATIENT,5,ML,30.77,18.462,,26.15,85,,20.92,Percent of total billed charges,85% of total billed charges,0.11,136.6,,31.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,246,fee schedule,136.60% of BCBS custom fee schedule,10.82,35.15,,3.432,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,3.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.69,38,,9.352,percent of total billed charges,38% of total billed charges,9.83,31.95,,4.296,percent of total billed charges,31.95% of total billed charges,0.11,814.73,
levETIRAcetam 100 mg/mL Sol [FMC],2582591,CDM,250,RC,J1953,HCPCS,OUTPATIENT,5,ML,30.77,18.462,,26.15,85,,20.92,Percent of total billed charges,85% of total billed charges,0.11,136.6,,246,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,380,fee schedule,136.60% of BCBS custom fee schedule,10.82,35.15,,43.144,percent of total billed charges,35.15% of total billed charges,821.12,31.95,,43.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.69,38,,9.352,percent of total billed charges,38% of total billed charges,9.83,31.95,,54.016,percent of total billed charges,31.95% of total billed charges,0.11,821.12,
levETIRAcetam 100 mg/mL Sol [FMC],2582591,CDM,250,RC,J1953,HCPCS,OUTPATIENT,5,ML,36.36,21.816,,30.91,85,,24.728,Percent of total billed charges,85% of total billed charges,0.11,136.6,,380,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,12.78,35.15,,43.144,percent of total billed charges,35.15% of total billed charges,837.41,31.95,,43.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.82,38,,11.056,percent of total billed charges,38% of total billed charges,11.62,31.95,,54.016,percent of total billed charges,31.95% of total billed charges,0.11,837.41,
levETIRAcetam 100 mg/mL Sol [FMC],2582591,CDM,250,RC,J1953,HCPCS,OUTPATIENT,5,ML,48.75,29.25,,41.44,85,,33.152,Percent of total billed charges,85% of total billed charges,0.11,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,61.2,fee schedule,136.60% of BCBS custom fee schedule,17.14,35.15,,20.888,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,20.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.53,38,,14.824,percent of total billed charges,38% of total billed charges,15.58,31.95,,26.144,percent of total billed charges,31.95% of total billed charges,0.11,862.65,
levETIRAcetam 100 mg/mL Sol [FMC],2582591,CDM,250,RC,J1953,HCPCS,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.11,136.6,,61.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,31.68,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,28.8,percent of total billed charges,31.95% of total billed charges,0.11,862.65,
doxapram 20 mg/mL IV Sol [FMC],2582617,CDM,250,RC,,,OUTPATIENT,20,ML,163.8,98.28,,139.23,85,,111.384,Percent of total billed charges,85% of total billed charges,81.9,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,81.9,50,,56.8,percent of total billed charges,50% of total billed charges,52.33,31.95,,7.136,percent of total billed charges,31.95% of total billed charges,52.33,31.95,,7.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,62.24,38,,49.792,percent of total billed charges,38% of total billed charges,65.52,40,,8.936,percent of total billed charges,40% of total billed charges,52.33,139.23,
prochlorperazine 10 mg Tab [FMC],2582625,CDM,250,RC,Q0164,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.78,136.6,,56.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.78,136.6,,63.6,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,28.952,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,28.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,36.24,percent of total billed charges,31.95% of total billed charges,0.78,862.65,
prochlorperazine 10 mg Tab [FMC],2582625,CDM,250,RC,Q0164,HCPCS,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,0.78,136.6,,63.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.78,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,1.096,percent of total billed charges,35.15% of total billed charges,898.43,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,0.96,31.95,,1,percent of total billed charges,31.95% of total billed charges,0.78,898.43,
Mineral oil ADULT enema 133 mL [FMC],2582633,CDM,250,RC,,,OUTPATIENT,133,ML,8.09,4.854,,6.88,85,,5.504,Percent of total billed charges,85% of total billed charges,4.05,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.05,50,,3.6,percent of total billed charges,50% of total billed charges,2.58,31.95,,1.096,percent of total billed charges,31.95% of total billed charges,2.58,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.07,38,,2.456,percent of total billed charges,38% of total billed charges,3.24,40,,1,percent of total billed charges,40% of total billed charges,2.58,6.88,
Mineral oil ADULT enema 133 mL [FMC],2582633,CDM,250,RC,,,OUTPATIENT,133,ML,8.5,5.1,,7.23,85,,5.784,Percent of total billed charges,85% of total billed charges,4.25,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.25,50,,172,percent of total billed charges,50% of total billed charges,2.72,31.95,,1.096,percent of total billed charges,31.95% of total billed charges,2.72,31.95,,69.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.23,38,,2.584,percent of total billed charges,38% of total billed charges,3.4,40,,1,percent of total billed charges,40% of total billed charges,2.72,7.23,
hydrogen peroxide Top 3% Sol [FMC],2582641,CDM,250,RC,,,OUTPATIENT,480,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,172,percent of total billed charges,50% of total billed charges,1.92,31.95,,4.072,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,4.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,5.096,percent of total billed charges,40% of total billed charges,1.92,5.1,
hydrogen peroxide Top 3% Sol [FMC],2582641,CDM,250,RC,,,OUTPATIENT,480,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,39.2,percent of total billed charges,50% of total billed charges,1.92,31.95,,4.2,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,4.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,5.256,percent of total billed charges,40% of total billed charges,1.92,5.1,
hydrogen peroxide topical 3% Solhydrogen peroxide Top 3% Sol [FMC],2582641,CDM,250,RC,,,OUTPATIENT,480,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,39.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,172,percent of total billed charges,50% of total billed charges,1.92,31.95,,4.072,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,4.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,5.096,percent of total billed charges,40% of total billed charges,1.92,5.1,
hydrogen peroxide topical 3% Solhydrogen peroxide Top 3% Sol [FMC],2582641,CDM,250,RC,,,OUTPATIENT,480,EA,11.54,6.924,,9.81,85,,7.848,Percent of total billed charges,85% of total billed charges,5.77,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.77,50,,18.4,percent of total billed charges,50% of total billed charges,3.69,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,3.69,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.39,38,,3.512,percent of total billed charges,38% of total billed charges,4.62,40,,0.96,percent of total billed charges,40% of total billed charges,3.69,9.81,
regadenoson 0.4 mg/5 mL IV Sol [FMC],2582658,CDM,250,RC,J2785,HCPCS,OUTPATIENT,5,ML,975.98,585.588,,829.58,85,,663.664,Percent of total billed charges,85% of total billed charges,52.24,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.24,136.6,,10.624,fee schedule,136.60% of BCBS custom fee schedule,343.06,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,311.83,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,370.87,38,,296.696,percent of total billed charges,38% of total billed charges,311.83,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,52.24,829.58,
testosterone cypionate 200 mg/mL IM Sol [FMC],2582674,CDM,250,RC,J1080,HCPCS,OUTPATIENT,1,ML,32.95,19.77,,28.01,85,,22.408,Percent of total billed charges,85% of total billed charges,16.48,50,,10.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.48,50,,367.2,percent of total billed charges,50% of total billed charges,11.58,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,898.43,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.52,38,,10.016,percent of total billed charges,38% of total billed charges,10.53,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,10.53,898.43,
testosterone cypionate 200 mg/mL IM Sol [FMC],2582674,CDM,250,RC,J1080,HCPCS,OUTPATIENT,1,ML,36.68,22.008,,31.18,85,,24.944,Percent of total billed charges,85% of total billed charges,18.34,50,,367.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.34,50,,172,percent of total billed charges,50% of total billed charges,12.89,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,913.13,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.94,38,,11.152,percent of total billed charges,38% of total billed charges,11.72,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,11.72,913.13,
testosterone cypionate 200 mg/mL IM Sol [FMC],2582674,CDM,250,RC,J1080,HCPCS,OUTPATIENT,1,ML,36.68,22.008,,31.18,85,,24.944,Percent of total billed charges,85% of total billed charges,18.34,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.34,50,,18.8,percent of total billed charges,50% of total billed charges,12.89,35.15,,1.712,percent of total billed charges,35.15% of total billed charges,913.13,31.95,,1.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.94,38,,11.152,percent of total billed charges,38% of total billed charges,11.72,31.95,,2.144,percent of total billed charges,31.95% of total billed charges,11.72,913.13,
testosterone cypionate 200 mg/mL IM Sol [FMC],2582674,CDM,250,RC,J1080,HCPCS,OUTPATIENT,1,ML,70.2,42.12,,59.67,85,,47.736,Percent of total billed charges,85% of total billed charges,35.1,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.1,50,,0.8,percent of total billed charges,50% of total billed charges,24.68,35.15,,1.696,percent of total billed charges,35.15% of total billed charges,945.72,31.95,,1.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.68,38,,21.344,percent of total billed charges,38% of total billed charges,22.43,31.95,,2.12,percent of total billed charges,31.95% of total billed charges,22.43,945.72,
testosterone cypionate 200 mg/mL IM Sol [FMC],2582674,CDM,250,RC,J1080,HCPCS,OUTPATIENT,1,ML,75.21,45.126,,63.93,85,,51.144,Percent of total billed charges,85% of total billed charges,37.61,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.61,50,,0.8,percent of total billed charges,50% of total billed charges,26.44,35.15,,1.712,percent of total billed charges,35.15% of total billed charges,952.11,31.95,,1.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.58,38,,22.864,percent of total billed charges,38% of total billed charges,24.03,31.95,,2.144,percent of total billed charges,31.95% of total billed charges,24.03,952.11,
antivenin (black widow spider) Inj 2.5 mL REC [FMC],2582815,CDM,250,RC,,,OUTPATIENT,1,ML,108.07,64.842,,91.86,85,,73.488,Percent of total billed charges,85% of total billed charges,54.04,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,54.04,50,,17.6,percent of total billed charges,50% of total billed charges,34.53,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,34.53,31.95,,1.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.07,38,,32.856,percent of total billed charges,38% of total billed charges,43.23,40,,1.36,percent of total billed charges,40% of total billed charges,34.53,91.86,
sterile water Inj 1000ml Sol [FMC],2582831,CDM,250,RC,A4217,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.23,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.23,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,4.52,percent of total billed charges,35.15% of total billed charges,63.9,31.95,,4.52,percent of total billed charges,31.95% of total billed charges,4.28,100,,,fee schedule,100% of CMS custom fee schedule,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,5.664,percent of total billed charges,31.95% of total billed charges,4.23,63.9,
sterile water Inj 1000ml Sol [FMC],2582831,CDM,250,RC,A4217,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.23,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.23,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,63.9,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,4.28,100,,,fee schedule,100% of CMS custom fee schedule,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,4.23,63.9,
sterile water Inj 1000ml Sol [FMC],2582831,CDM,250,RC,A4217,HCPCS,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,4.23,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.23,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,6.4,percent of total billed charges,35.15% of total billed charges,63.9,31.95,,6.4,percent of total billed charges,31.95% of total billed charges,4.28,100,,,fee schedule,100% of CMS custom fee schedule,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,8.016,percent of total billed charges,31.95% of total billed charges,4.23,63.9,
"heparin 25,000 units/250 mL-D5W IV Sol [FMC]",2582849,CDM,250,RC,J1644,HCPCS,OUTPATIENT,250,ML,32.91,19.746,,27.97,85,,22.376,Percent of total billed charges,85% of total billed charges,0.42,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,11.57,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,10.51,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.51,38,,10.008,percent of total billed charges,38% of total billed charges,10.51,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,0.42,27.97,
"heparin 25,000 units/250 mL-D5W IV Sol [FMC]",2582849,CDM,250,RC,J1644,HCPCS,OUTPATIENT,250,ML,32.13,19.278,,27.31,85,,21.848,Percent of total billed charges,85% of total billed charges,0.42,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,11.29,35.15,,4.128,fee schedule,35.15% of LA custom fee schedule,10.27,31.95,,4.128,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.21,38,,9.768,percent of total billed charges,38% of total billed charges,10.27,31.95,,5.168,Fee Schedule,31.95% of LA custom fee schedule,0.42,27.31,
"heparin 25,000 units/250 mL-D5W IV Sol [FMC]",2582849,CDM,250,RC,J1644,HCPCS,OUTPATIENT,250,ML,37.54,22.524,,31.91,85,,25.528,Percent of total billed charges,85% of total billed charges,0.42,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,13.2,35.15,,4.64,fee schedule,35.15% of LA custom fee schedule,11.99,31.95,,4.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.27,38,,11.416,percent of total billed charges,38% of total billed charges,11.99,31.95,,5.808,Fee Schedule,31.95% of LA custom fee schedule,0.42,31.91,
phytonadione 5 mg Tab [FMC],2582872,CDM,250,RC,,,OUTPATIENT,1,EA,208.33,124.998,,177.08,85,,141.664,Percent of total billed charges,85% of total billed charges,104.17,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,104.17,50,,988,percent of total billed charges,50% of total billed charges,66.56,31.95,,570.272,percent of total billed charges,31.95% of total billed charges,66.56,31.95,,69.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.17,38,,63.336,percent of total billed charges,38% of total billed charges,83.33,40,,518.36,percent of total billed charges,40% of total billed charges,66.56,177.08,
phytonadione 5 mg Tab [FMC],2582872,CDM,250,RC,,,OUTPATIENT,1,EA,217.71,130.626,,185.05,85,,148.04,Percent of total billed charges,85% of total billed charges,108.86,50,,988,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108.86,50,,388.8,percent of total billed charges,50% of total billed charges,69.56,31.95,,11.32,percent of total billed charges,31.95% of total billed charges,69.56,31.95,,11.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.73,38,,66.184,percent of total billed charges,38% of total billed charges,87.08,40,,14.176,percent of total billed charges,40% of total billed charges,69.56,185.05,
phytonadione 5 mg Tab [FMC],2582872,CDM,250,RC,,,OUTPATIENT,1,EA,217.71,130.626,,185.05,85,,148.04,Percent of total billed charges,85% of total billed charges,108.86,50,,388.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108.86,50,,312,percent of total billed charges,50% of total billed charges,69.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,69.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.73,38,,66.184,percent of total billed charges,38% of total billed charges,87.08,40,,0.96,percent of total billed charges,40% of total billed charges,69.56,185.05,
oxyCODONE 5 mg IR Tab [FMC],2582922,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,172,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
oxyCODONE 5 mg IR Tab [FMC],2582922,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,172,percent of total billed charges,50% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,0.96,percent of total billed charges,40% of total billed charges,1.28,3.4,
oxyCODONE 5 mg IR Tab [FMC],2582922,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,848,percent of total billed charges,50% of total billed charges,1.28,31.95,,1175,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,69.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1068.032,percent of total billed charges,40% of total billed charges,1.28,3.4,
oxyCODONE 5 mg IR Tab [FMC],2582922,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,848,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,52.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,49.344,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,49.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,61.776,percent of total billed charges,40% of total billed charges,1.28,3.4,
ertapenem 1 gm Inj [FMC],2582989,CDM,250,RC,J1335,HCPCS,OUTPATIENT,1,EA,501.77,301.062,,426.5,85,,341.2,Percent of total billed charges,85% of total billed charges,19.82,136.6,,52.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,176.37,35.15,,13.808,percent of total billed charges,35.15% of total billed charges,64.54,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190.67,38,,152.536,percent of total billed charges,38% of total billed charges,160.32,31.95,,12.552,percent of total billed charges,31.95% of total billed charges,19.82,426.5,
ertapenem 1 gm Inj [FMC],2582989,CDM,250,RC,J1335,HCPCS,OUTPATIENT,1,EA,456.57,273.942,,388.08,85,,310.464,Percent of total billed charges,85% of total billed charges,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,160.48,35.15,,4.736,percent of total billed charges,35.15% of total billed charges,65.47,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,173.5,38,,138.8,percent of total billed charges,38% of total billed charges,145.87,31.95,,4.304,percent of total billed charges,31.95% of total billed charges,19.82,388.08,
ertapenem 1 gm Inj [FMC],2582989,CDM,250,RC,J1335,HCPCS,OUTPATIENT,1,EA,289.67,173.802,,246.22,85,,196.976,Percent of total billed charges,85% of total billed charges,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,101.82,35.15,,11.376,percent of total billed charges,35.15% of total billed charges,65.47,31.95,,11.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.07,38,,88.056,percent of total billed charges,38% of total billed charges,92.55,31.95,,14.24,percent of total billed charges,31.95% of total billed charges,19.82,246.22,
ertapenem 1 gm Inj [FMC],2582989,CDM,250,RC,J1335,HCPCS,OUTPATIENT,1,EA,312,187.2,,265.2,85,,212.16,Percent of total billed charges,85% of total billed charges,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,109.67,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,66.46,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,118.56,38,,94.848,percent of total billed charges,38% of total billed charges,99.68,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,19.82,265.2,
ertapenem 1 gm Inj [FMC],2582989,CDM,250,RC,J1335,HCPCS,OUTPATIENT,1,EA,390,234,,331.5,85,,265.2,Percent of total billed charges,85% of total billed charges,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,137.09,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,70.29,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,148.2,38,,118.56,percent of total billed charges,38% of total billed charges,124.61,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,19.82,331.5,
ertapenem 1 gm Inj [FMC],2582989,CDM,250,RC,J1335,HCPCS,OUTPATIENT,1,EA,456.57,273.942,,388.08,85,,310.464,Percent of total billed charges,85% of total billed charges,19.82,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.82,136.6,,52.8,fee schedule,136.60% of BCBS custom fee schedule,160.48,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,70.35,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,173.5,38,,138.8,percent of total billed charges,38% of total billed charges,145.87,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,19.82,388.08,
Dextrose 5% in water and 0.45% Sodium Chloride IV Sol 500 mL [FMC],2582997,CDM,250,RC,S5010,HCPCS,OUTPATIENT,500,ML,37.99,22.794,,32.29,85,,25.832,Percent of total billed charges,85% of total billed charges,7.51,136.6,,52.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.51,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,13.35,35.15,,1151.512,percent of total billed charges,35.15% of total billed charges,73.49,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,11.552,percent of total billed charges,38% of total billed charges,12.14,31.95,,1046.68,percent of total billed charges,31.95% of total billed charges,7.51,73.49,
vancomycin 250 mg Cap [FMC],2583011,CDM,250,RC,,,OUTPATIENT,1,EA,187.58,112.548,,159.44,85,,127.552,Percent of total billed charges,85% of total billed charges,93.79,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,93.79,50,,148.8,percent of total billed charges,50% of total billed charges,59.93,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,59.93,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.28,38,,57.024,percent of total billed charges,38% of total billed charges,75.03,40,,1.28,percent of total billed charges,40% of total billed charges,59.93,159.44,
vancomycin 250 mg Cap [FMC],2583011,CDM,250,RC,,,OUTPATIENT,1,EA,187.58,112.548,,159.44,85,,127.552,Percent of total billed charges,85% of total billed charges,93.79,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,93.79,50,,553.2,percent of total billed charges,50% of total billed charges,59.93,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,59.93,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.28,38,,57.024,percent of total billed charges,38% of total billed charges,75.03,40,,5.68,percent of total billed charges,40% of total billed charges,59.93,159.44,
vancomycin 250 mg Cap [FMC],2583011,CDM,250,RC,,,OUTPATIENT,1,EA,187.58,112.548,,159.44,85,,127.552,Percent of total billed charges,85% of total billed charges,93.79,50,,553.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,93.79,50,,12,percent of total billed charges,50% of total billed charges,59.93,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,59.93,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.28,38,,57.024,percent of total billed charges,38% of total billed charges,75.03,40,,0.96,percent of total billed charges,40% of total billed charges,59.93,159.44,
vancomycin 250 mg Cap [FMC],2583011,CDM,250,RC,,,OUTPATIENT,1,EA,187.58,112.548,,159.44,85,,127.552,Percent of total billed charges,85% of total billed charges,93.79,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,93.79,50,,10,percent of total billed charges,50% of total billed charges,59.93,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,59.93,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.28,38,,57.024,percent of total billed charges,38% of total billed charges,75.03,40,,1.28,percent of total billed charges,40% of total billed charges,59.93,159.44,
Dextrose 5% in water and 0.2% Sodium Chloride IV Sol 500 mL [FMC],2583037,CDM,250,RC,J7042,HCPCS,OUTPATIENT,500,ML,37.8,22.68,,32.13,85,,25.704,Percent of total billed charges,85% of total billed charges,1.76,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.76,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,13.29,35.15,,20.104,percent of total billed charges,35.15% of total billed charges,73.49,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.36,38,,11.488,percent of total billed charges,38% of total billed charges,12.08,31.95,,18.272,percent of total billed charges,31.95% of total billed charges,1.76,73.49,
fesoterodine 4 mg ER [FMC],2583045,CDM,250,RC,,,OUTPATIENT,1,EA,28.14,16.884,,23.92,85,,19.136,Percent of total billed charges,85% of total billed charges,14.07,50,,60,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.07,50,,48,percent of total billed charges,50% of total billed charges,8.99,31.95,,33.288,percent of total billed charges,31.95% of total billed charges,8.99,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.69,38,,8.552,percent of total billed charges,38% of total billed charges,11.26,40,,30.256,percent of total billed charges,40% of total billed charges,8.99,23.92,
fesoterodine 4 mg ER [FMC],2583045,CDM,250,RC,,,OUTPATIENT,1,EA,44.05,26.43,,37.44,85,,29.952,Percent of total billed charges,85% of total billed charges,22.03,50,,48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.03,50,,48,percent of total billed charges,50% of total billed charges,14.07,31.95,,21.936,percent of total billed charges,31.95% of total billed charges,14.07,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.74,38,,13.392,percent of total billed charges,38% of total billed charges,17.62,40,,19.936,percent of total billed charges,40% of total billed charges,14.07,37.44,
polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Sol  [FMC],2583060,CDM,250,RC,,,OUTPATIENT,10,EA,56.62,33.972,,48.13,85,,38.504,Percent of total billed charges,85% of total billed charges,28.31,50,,48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.31,50,,7.2,percent of total billed charges,50% of total billed charges,18.09,31.95,,32.44,percent of total billed charges,31.95% of total billed charges,18.09,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.52,38,,17.216,percent of total billed charges,38% of total billed charges,22.65,40,,29.488,percent of total billed charges,40% of total billed charges,18.09,48.13,
polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Sol  [FMC],2583060,CDM,250,RC,,,OUTPATIENT,10,EA,43.68,26.208,,37.13,85,,29.704,Percent of total billed charges,85% of total billed charges,21.84,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.84,50,,34,percent of total billed charges,50% of total billed charges,13.96,31.95,,22.704,percent of total billed charges,31.95% of total billed charges,13.96,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.6,38,,13.28,percent of total billed charges,38% of total billed charges,17.47,40,,20.64,percent of total billed charges,40% of total billed charges,13.96,37.13,
linagliptin 5 mg Tab [FMC],2583078,CDM,250,RC,,,OUTPATIENT,1,EA,39.08,23.448,,33.22,85,,26.576,Percent of total billed charges,85% of total billed charges,19.54,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.54,50,,53.632,percent of total billed charges,50% of total billed charges,12.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,12.49,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.85,38,,11.88,percent of total billed charges,38% of total billed charges,15.63,40,,0.96,percent of total billed charges,40% of total billed charges,12.49,33.22,
lactulose 20 g/30 mL Syr UD [FMC],2583136,CDM,250,RC,,,OUTPATIENT,30,ML,3.09,1.854,,2.63,85,,2.104,Percent of total billed charges,85% of total billed charges,1.55,50,,53.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.55,50,,7.2,percent of total billed charges,50% of total billed charges,0.99,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.17,38,,0.936,percent of total billed charges,38% of total billed charges,1.24,40,,0.96,percent of total billed charges,40% of total billed charges,0.99,2.63,
lactulose 20 g/30 mL Syr UD [FMC],2583136,CDM,250,RC,,,OUTPATIENT,30,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,0.96,2.55,
trimethobenzamide 100 mg/mL Sol [FMC],2583144,CDM,250,RC,J3250,HCPCS,OUTPATIENT,1,ML,51.9,31.14,,44.12,85,,35.296,Percent of total billed charges,85% of total billed charges,67.55,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,67.55,136.6,,54,fee schedule,136.60% of BCBS custom fee schedule,18.24,35.15,,75.616,fee schedule,35.15% of LA custom fee schedule,16.58,31.95,,75.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.72,38,,15.776,percent of total billed charges,38% of total billed charges,16.58,31.95,,94.672,Fee Schedule,31.95% of LA custom fee schedule,16.58,67.55,
phosphorus supplement 250mg tab [FMC],2583151,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,54,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,62.304,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,62.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,78,percent of total billed charges,40% of total billed charges,0.96,2.55,
phosphorus supplement 250mg tab [FMC],2583151,CDM,250,RC,,,OUTPATIENT,1,EA,3.6,2.16,,3.06,85,,2.448,Percent of total billed charges,85% of total billed charges,1.8,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.8,50,,172,percent of total billed charges,50% of total billed charges,1.15,31.95,,53.832,percent of total billed charges,31.95% of total billed charges,1.15,31.95,,53.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.37,38,,1.096,percent of total billed charges,38% of total billed charges,1.44,40,,67.392,percent of total billed charges,40% of total billed charges,1.15,3.06,
"bupivacaine-EPINEPHrine 0.5%-1:200,000 Sol 50mL [FMC]",2583169,CDM,250,RC,,,OUTPATIENT,50,ML,51.51,30.906,,43.78,85,,35.024,Percent of total billed charges,85% of total billed charges,25.76,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.76,50,,172,percent of total billed charges,50% of total billed charges,16.46,31.95,,44.848,percent of total billed charges,31.95% of total billed charges,16.46,31.95,,44.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.57,38,,15.656,percent of total billed charges,38% of total billed charges,20.6,40,,56.152,percent of total billed charges,40% of total billed charges,16.46,43.78,
"bupivacaine-EPINEPHrine 0.5%-1:200,000 Sol [FMC]",2583169,CDM,250,RC,,,OUTPATIENT,50,ML,48.67,29.202,,41.37,85,,33.096,Percent of total billed charges,85% of total billed charges,24.34,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.34,50,,172,percent of total billed charges,50% of total billed charges,15.55,31.95,,68.024,percent of total billed charges,31.95% of total billed charges,15.55,31.95,,68.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.49,38,,14.792,percent of total billed charges,38% of total billed charges,19.47,40,,85.168,percent of total billed charges,40% of total billed charges,15.55,41.37,
bupivacaine 0.5% Inj Sol 50 mL [FMC],2583201,CDM,250,RC,J0665,HCPCS,OUTPATIENT,50,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.03,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,46.08,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,105.496,percent of total billed charges,35.15% of total billed charges,73.49,31.95,,105.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,132.08,percent of total billed charges,31.95% of total billed charges,0.03,73.49,
bupivacaine 0.5% Inj Sol 50 mL [FMC],2583201,CDM,250,RC,J0665,HCPCS,OUTPATIENT,50,ML,43.68,26.208,,37.13,85,,29.704,Percent of total billed charges,85% of total billed charges,0.03,136.6,,46.08,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,3.16,fee schedule,136.60% of BCBS custom fee schedule,15.35,35.15,,175.976,percent of total billed charges,35.15% of total billed charges,73.49,31.95,,175.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.6,38,,13.28,percent of total billed charges,38% of total billed charges,13.96,31.95,,220.312,percent of total billed charges,31.95% of total billed charges,0.03,73.49,
bupivacaine 0.5% Inj Sol 50 mL [FMC],2583201,CDM,250,RC,J0665,HCPCS,OUTPATIENT,50,ML,19.83,11.898,,16.86,85,,13.488,Percent of total billed charges,85% of total billed charges,0.03,136.6,,3.16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,6.97,35.15,,196.976,percent of total billed charges,35.15% of total billed charges,74.12,31.95,,196.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.54,38,,6.032,percent of total billed charges,38% of total billed charges,6.34,31.95,,246.608,percent of total billed charges,31.95% of total billed charges,0.03,74.12,
bupivacaine 0.5% Inj Sol 50 mL [FMC],2583201,CDM,250,RC,J0665,HCPCS,OUTPATIENT,50,ML,13.44,8.064,,11.42,85,,9.136,Percent of total billed charges,85% of total billed charges,0.03,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,148.8,fee schedule,136.60% of BCBS custom fee schedule,4.72,35.15,,6.4,percent of total billed charges,35.15% of total billed charges,76.36,31.95,,6.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.11,38,,4.088,percent of total billed charges,38% of total billed charges,4.29,31.95,,8.016,percent of total billed charges,31.95% of total billed charges,0.03,76.36,
warfarin 1 mg Tab [FMC],2583250,CDM,250,RC,,,OUTPATIENT,1,EA,8.04,4.824,,6.83,85,,5.464,Percent of total billed charges,85% of total billed charges,4.02,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.02,50,,312,percent of total billed charges,50% of total billed charges,2.57,31.95,,2915.928,percent of total billed charges,31.95% of total billed charges,2.57,31.95,,2915.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.06,38,,2.448,percent of total billed charges,38% of total billed charges,3.22,40,,3650.616,percent of total billed charges,40% of total billed charges,2.57,6.83,
warfarin 1 mg Tab [FMC],2583250,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,5.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,49.432,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,49.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,61.888,percent of total billed charges,40% of total billed charges,0.96,2.55,
warfarin 1 mg Tab [FMC],2583250,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,9.112,percent of total billed charges,50% of total billed charges,0.96,31.95,,4.208,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,4.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,5.264,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrocortisone sodium succinate 100mg Sol [FMC],2583284,CDM,250,RC,J1720,HCPCS,OUTPATIENT,1,ML,26.7,16.02,,22.7,85,,18.16,Percent of total billed charges,85% of total billed charges,26.56,136.6,,9.112,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.56,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,9.39,35.15,,9.056,fee schedule,35.15% of LA custom fee schedule,8.53,31.95,,9.056,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.15,38,,8.12,percent of total billed charges,38% of total billed charges,8.53,31.95,,11.336,Fee Schedule,31.95% of LA custom fee schedule,8.53,26.56,
hydrocodone-acetaminophen 10 mg-325 mg Tab [FMC],2583300,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,308.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,279.976,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 10 mg-325 mg Tab [FMC],2583300,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,13.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,87.952,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,71.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,79.944,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 10 mg-325 mg Tab [FMC],2583300,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,6,percent of total billed charges,50% of total billed charges,1.28,31.95,,38.456,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,38.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,48.144,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 10 mg-325 mg Tab [FMC],2583300,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,18,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.936,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.576,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 10 mg-325 mg Tab [FMC],2583300,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,37.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,72.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3.064,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 10 mg-325 mg Tab [FMC],2583300,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,37.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,10.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,3564.208,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,72.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,3239.728,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 10 mg-325 mg Tab [FMC],2583300,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,49.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,1781.6,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,72.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1619.408,percent of total billed charges,40% of total billed charges,1.28,3.4,
levothyroxine 100 mcg (0.1 mg) REC [FMC],2583334,CDM,250,RC,,,OUTPATIENT,1,EA,411.78,247.068,,350.01,85,,280.008,Percent of total billed charges,85% of total billed charges,205.89,50,,49.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,205.89,50,,0.64,percent of total billed charges,50% of total billed charges,131.56,31.95,,1958.8,percent of total billed charges,31.95% of total billed charges,131.56,31.95,,72.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,156.48,38,,125.184,percent of total billed charges,38% of total billed charges,164.71,40,,1780.472,percent of total billed charges,40% of total billed charges,131.56,350.01,
levothyroxine 100 mcg (0.1 mg) REC [FMC],2583334,CDM,250,RC,,,OUTPATIENT,1,EA,358.05,214.83,,304.34,85,,243.472,Percent of total billed charges,85% of total billed charges,179.03,50,,0.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,179.03,50,,89.128,percent of total billed charges,50% of total billed charges,114.4,31.95,,5.064,percent of total billed charges,31.95% of total billed charges,114.4,31.95,,5.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,136.06,38,,108.848,percent of total billed charges,38% of total billed charges,143.22,40,,6.336,percent of total billed charges,40% of total billed charges,114.4,304.34,
povidone-iodine oint 10% max strength 30 gm [FMC],2583375,CDM,250,RC,,,OUTPATIENT,30,EA,20.8,12.48,,17.68,85,,14.144,Percent of total billed charges,85% of total billed charges,10.4,50,,89.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.4,50,,57.68,percent of total billed charges,50% of total billed charges,6.65,31.95,,3.528,percent of total billed charges,31.95% of total billed charges,6.65,31.95,,3.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.9,38,,6.32,percent of total billed charges,38% of total billed charges,8.32,40,,4.416,percent of total billed charges,40% of total billed charges,6.65,17.68,
octreotide 100 mcg/mL Inj Sol [FMC],2583383,CDM,250,RC,J2354,HCPCS,OUTPATIENT,1,ML,69.65,41.79,,59.2,85,,47.36,Percent of total billed charges,85% of total billed charges,1.68,136.6,,57.68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.68,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,24.48,35.15,,24.92,fee schedule,35.15% of LA custom fee schedule,22.25,31.95,,24.92,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,26.47,38,,21.176,percent of total billed charges,38% of total billed charges,22.25,31.95,,31.2,Fee Schedule,31.95% of LA custom fee schedule,1.68,59.2,
octreotide 100 mcg/mL Inj Sol [FMC],2583383,CDM,250,RC,J2354,HCPCS,OUTPATIENT,1,ML,99.7,59.82,,84.75,85,,67.8,Percent of total billed charges,85% of total billed charges,1.68,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.68,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,35.04,35.15,,4.16,fee schedule,35.15% of LA custom fee schedule,31.85,31.95,,72.464,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,37.89,38,,30.312,percent of total billed charges,38% of total billed charges,31.85,31.95,,3.776,Fee Schedule,31.95% of LA custom fee schedule,1.68,84.75,
octreotide 100 mcg/mL Inj Sol [FMC],2583383,CDM,250,RC,J2354,HCPCS,OUTPATIENT,1,ML,38.77,23.262,,32.95,85,,26.36,Percent of total billed charges,85% of total billed charges,1.68,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.68,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,13.63,35.15,,8.632,fee schedule,35.15% of LA custom fee schedule,12.39,31.95,,72.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.73,38,,11.784,percent of total billed charges,38% of total billed charges,12.39,31.95,,7.848,Fee Schedule,31.95% of LA custom fee schedule,1.68,32.95,
octreotide 100 mcg/mL Inj Sol [FMC],2583383,CDM,250,RC,J2354,HCPCS,OUTPATIENT,1,ML,38.77,23.262,,32.95,85,,26.36,Percent of total billed charges,85% of total billed charges,1.68,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.68,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,13.63,35.15,,4.408,fee schedule,35.15% of LA custom fee schedule,12.39,31.95,,74.128,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.73,38,,11.784,percent of total billed charges,38% of total billed charges,12.39,31.95,,4.008,Fee Schedule,31.95% of LA custom fee schedule,1.68,32.95,
octreotide 100 mcg/mL Inj Sol [FMC],2583383,CDM,250,RC,J2354,HCPCS,OUTPATIENT,1,ML,25.35,15.21,,21.55,85,,17.24,Percent of total billed charges,85% of total billed charges,1.68,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.68,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,8.91,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,8.1,31.95,,74.128,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.63,38,,7.704,percent of total billed charges,38% of total billed charges,8.1,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,1.68,21.55,
butorphanol 2 mg/mL Inj Sol [FMC],2583391,CDM,250,RC,J0595,HCPCS,OUTPATIENT,1,ML,24.17,14.502,,20.54,85,,16.432,Percent of total billed charges,85% of total billed charges,3.81,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.81,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,8.5,35.15,,27.984,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.18,38,,7.344,percent of total billed charges,38% of total billed charges,7.72,31.95,,25.44,percent of total billed charges,31.95% of total billed charges,3.81,20.54,
Heparin Lock flush Port 100u/ml YELLOW Syringe 5mL [FMC],2583409,CDM,250,RC,J1642,HCPCS,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.03,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,26.88,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,26.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,33.656,Fee Schedule,31.95% of LA custom fee schedule,0.03,10.2,
Heparin Lock flush Port 100u/ml YELLOW Syringe 5mL [FMC],2583409,CDM,250,RC,J1642,HCPCS,OUTPATIENT,5,ML,12.06,7.236,,10.25,85,,8.2,Percent of total billed charges,85% of total billed charges,0.03,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,16.8,fee schedule,136.60% of BCBS custom fee schedule,4.24,35.15,,41.232,fee schedule,35.15% of LA custom fee schedule,3.85,31.95,,41.232,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.58,38,,3.664,percent of total billed charges,38% of total billed charges,3.85,31.95,,51.616,Fee Schedule,31.95% of LA custom fee schedule,0.03,10.25,
Heparin Lock flush Port 100u/ml YELLOW Syringe 5mL [FMC],2583409,CDM,250,RC,J1642,HCPCS,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.03,136.6,,16.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,1.184,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,50.448,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,74.632,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,45.856,Fee Schedule,31.95% of LA custom fee schedule,0.03,10.2,
piperacillin-tazobactam 4 g-0.5 g REC [FMC],2583417,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,57.21,34.326,,48.63,85,,38.904,Percent of total billed charges,85% of total billed charges,1.34,136.6,,1.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,20.11,35.15,,16.088,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,16.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.74,38,,17.392,percent of total billed charges,38% of total billed charges,18.28,31.95,,20.144,percent of total billed charges,31.95% of total billed charges,1.34,48.63,
piperacillin-tazobactam 4 g-0.5 g REC [FMC],2583417,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,89.54,53.724,,76.11,85,,60.888,Percent of total billed charges,85% of total billed charges,1.34,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,89.2,fee schedule,136.60% of BCBS custom fee schedule,31.47,35.15,,16.976,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,16.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.03,38,,27.224,percent of total billed charges,38% of total billed charges,28.61,31.95,,21.256,percent of total billed charges,31.95% of total billed charges,1.34,76.11,
piperacillin-tazobactam 4 g-0.5 g REC [FMC],2583417,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,60.84,36.504,,51.71,85,,41.368,Percent of total billed charges,85% of total billed charges,1.34,136.6,,89.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,63.6,fee schedule,136.60% of BCBS custom fee schedule,21.39,35.15,,1.536,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.12,38,,18.496,percent of total billed charges,38% of total billed charges,19.44,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,1.34,51.71,
piperacillin-tazobactam 4 g-0.5 g REC [FMC],2583417,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,68.48,41.088,,58.21,85,,46.568,Percent of total billed charges,85% of total billed charges,1.34,136.6,,63.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,24.07,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.02,38,,20.816,percent of total billed charges,38% of total billed charges,21.88,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1.34,58.21,
piperacillin-tazobactam 4 g-0.5 g REC [FMC],2583417,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,32.65,19.59,,27.75,85,,22.2,Percent of total billed charges,85% of total billed charges,1.34,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,11.48,35.15,,500.68,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.41,38,,9.928,percent of total billed charges,38% of total billed charges,10.43,31.95,,455.096,percent of total billed charges,31.95% of total billed charges,1.34,27.75,
piperacillin-tazobactam 4 g-0.5 g REC [FMC],2583417,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,89.54,53.724,,76.11,85,,60.888,Percent of total billed charges,85% of total billed charges,1.34,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,31.47,35.15,,5.888,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,5.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.03,38,,27.224,percent of total billed charges,38% of total billed charges,28.61,31.95,,7.376,percent of total billed charges,31.95% of total billed charges,1.34,76.11,
piperacillin-tazobactam 4 g-0.5 g REC [FMC],2583417,CDM,250,RC,J2543,HCPCS,OUTPATIENT,1,EA,70.69,42.414,,60.09,85,,48.072,Percent of total billed charges,85% of total billed charges,1.34,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.34,136.6,,10.36,fee schedule,136.60% of BCBS custom fee schedule,24.85,35.15,,63.104,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,63.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.86,38,,21.488,percent of total billed charges,38% of total billed charges,22.59,31.95,,79,percent of total billed charges,31.95% of total billed charges,1.34,60.09,
apixaban 2.5 mg Tab UD [FMC],2583441,CDM,250,RC,,,OUTPATIENT,1,EA,34.39,20.634,,29.23,85,,23.384,Percent of total billed charges,85% of total billed charges,17.2,50,,10.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.2,50,,8.8,percent of total billed charges,50% of total billed charges,10.99,31.95,,50.408,percent of total billed charges,31.95% of total billed charges,10.99,31.95,,50.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.07,38,,10.456,percent of total billed charges,38% of total billed charges,13.76,40,,63.104,percent of total billed charges,40% of total billed charges,10.99,29.23,
apixaban 2.5 mg Tab UD [FMC],2583441,CDM,250,RC,,,OUTPATIENT,1,EA,27.24,16.344,,23.15,85,,18.52,Percent of total billed charges,85% of total billed charges,13.62,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.62,50,,1.2,percent of total billed charges,50% of total billed charges,8.7,31.95,,60.272,percent of total billed charges,31.95% of total billed charges,8.7,31.95,,60.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.35,38,,8.28,percent of total billed charges,38% of total billed charges,10.9,40,,75.464,percent of total billed charges,40% of total billed charges,8.7,23.15,
tetanus immune globulin 250 units IM Sol 1 EA [FMC],2583458,CDM,250,RC,J1670,HCPCS,OUTPATIENT,1,EA,2169.96,1301.976,,1844.47,85,,1475.576,Percent of total billed charges,85% of total billed charges,878.11,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,878.11,136.6,,57.6,fee schedule,136.60% of BCBS custom fee schedule,762.74,35.15,,37.816,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,37.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,824.58,38,,659.664,percent of total billed charges,38% of total billed charges,693.3,31.95,,47.344,percent of total billed charges,31.95% of total billed charges,7.86,1844.47,
"dextromethorphan 30 mg/5 mL Oral Susp, ER [FMC]",2583466,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,57.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,82.88,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,82.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,103.76,percent of total billed charges,40% of total billed charges,0.96,2.55,
"dextromethorphan 30 mg/5 mL Oral Susp, ER [FMC]",2583466,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,0.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,32.432,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,32.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,40.608,percent of total billed charges,40% of total billed charges,0.96,2.55,
canagliflozin 300 mg Tab [FMC],2583482,CDM,250,RC,,,OUTPATIENT,1,EA,42.91,25.746,,36.47,85,,29.176,Percent of total billed charges,85% of total billed charges,21.46,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.46,50,,38,percent of total billed charges,50% of total billed charges,13.71,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,13.71,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.31,38,,13.048,percent of total billed charges,38% of total billed charges,17.16,40,,11.52,percent of total billed charges,40% of total billed charges,13.71,36.47,
lidocaine topical 5% Ointment 35.44 gm [FMC],2583532,CDM,250,RC,,,OUTPATIENT,35.44,EA,975,585,,828.75,85,,663,Percent of total billed charges,85% of total billed charges,487.5,50,,38,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,487.5,50,,16,percent of total billed charges,50% of total billed charges,311.51,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,311.51,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,370.5,38,,296.4,percent of total billed charges,38% of total billed charges,390,40,,11.52,percent of total billed charges,40% of total billed charges,311.51,828.75,
lidocaine topical 5% Ointment 35.44 gm [FMC],2583532,CDM,250,RC,,,OUTPATIENT,35.44,EA,936,561.6,,795.6,85,,636.48,Percent of total billed charges,85% of total billed charges,468,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,468,50,,1.6,percent of total billed charges,50% of total billed charges,299.05,31.95,,7.896,percent of total billed charges,31.95% of total billed charges,299.05,31.95,,7.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,355.68,38,,284.544,percent of total billed charges,38% of total billed charges,374.4,40,,9.888,percent of total billed charges,40% of total billed charges,299.05,795.6,
lidocaine topical 5% Ointment 50  gm [FMC],2583532,CDM,250,RC,,,OUTPATIENT,35.44,EA,876.52,525.912,,745.04,85,,596.032,Percent of total billed charges,85% of total billed charges,438.26,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,438.26,50,,26.56,percent of total billed charges,50% of total billed charges,280.05,31.95,,6.824,percent of total billed charges,31.95% of total billed charges,280.05,31.95,,6.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,333.08,38,,266.464,percent of total billed charges,38% of total billed charges,350.61,40,,8.544,percent of total billed charges,40% of total billed charges,280.05,745.04,
lidocaine topical 5% Ointment 50 gm [FMC],2583532,CDM,250,RC,,,OUTPATIENT,35.44,EA,877.51,526.506,,745.88,85,,596.704,Percent of total billed charges,85% of total billed charges,438.76,50,,26.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,438.76,50,,5.04,percent of total billed charges,50% of total billed charges,280.36,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,280.36,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,333.45,38,,266.76,percent of total billed charges,38% of total billed charges,351,40,,11.52,percent of total billed charges,40% of total billed charges,280.36,745.88,
lidocaine topical 5% Ointment 50 gm [FMC],2583532,CDM,250,RC,,,OUTPATIENT,35.44,EA,877.51,526.506,,745.88,85,,596.704,Percent of total billed charges,85% of total billed charges,438.76,50,,5.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,438.76,50,,574.4,percent of total billed charges,50% of total billed charges,280.36,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,280.36,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,333.45,38,,266.76,percent of total billed charges,38% of total billed charges,351,40,,11.52,percent of total billed charges,40% of total billed charges,280.36,745.88,
esmolol 10 mg/mL IV 250ml Sol [FMC],2583581,CDM,250,RC,,,OUTPATIENT,250,ML,1823.93,1094.358,,1550.34,85,,1240.272,Percent of total billed charges,85% of total billed charges,911.97,50,,574.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,911.97,50,,2.4,percent of total billed charges,50% of total billed charges,582.75,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,582.75,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,693.09,38,,554.472,percent of total billed charges,38% of total billed charges,729.57,40,,11.52,percent of total billed charges,40% of total billed charges,582.75,1550.34,
esmolol 10 mg/mL IV 250ml Sol [FMC],2583581,CDM,250,RC,,,OUTPATIENT,250,ML,362.42,217.452,,308.06,85,,246.448,Percent of total billed charges,85% of total billed charges,181.21,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,181.21,50,,2,percent of total billed charges,50% of total billed charges,115.79,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,115.79,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,137.72,38,,110.176,percent of total billed charges,38% of total billed charges,144.97,40,,11.52,percent of total billed charges,40% of total billed charges,115.79,308.06,
acetylcysteine 20% Sol IV 30ML [FMC],2583631,CDM,250,RC,J0132,HCPCS,OUTPATIENT,30,ML,429,257.4,,364.65,85,,291.72,Percent of total billed charges,85% of total billed charges,0.98,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,9.2,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,11.52,percent of total billed charges,31.95% of total billed charges,0.98,364.65,
acetylcysteine 20% Sol IV 30ML [FMC],2583631,CDM,250,RC,J0132,HCPCS,OUTPATIENT,30,ML,733.2,439.92,,623.22,85,,498.576,Percent of total billed charges,85% of total billed charges,0.98,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,54.8,fee schedule,136.60% of BCBS custom fee schedule,257.72,35.15,,9.2,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,278.62,38,,222.896,percent of total billed charges,38% of total billed charges,234.26,31.95,,11.52,percent of total billed charges,31.95% of total billed charges,0.98,623.22,
acetylcysteine 20% Sol IV 30ML [FMC],2583631,CDM,250,RC,J0132,HCPCS,OUTPATIENT,30,ML,585,351,,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,0.98,136.6,,54.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,4.224,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,9.2,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,222.3,38,,177.84,percent of total billed charges,38% of total billed charges,186.91,31.95,,11.52,percent of total billed charges,31.95% of total billed charges,0.98,497.25,
acetylcysteine 20% Sol IV 30ML [FMC],2583631,CDM,250,RC,J0132,HCPCS,OUTPATIENT,30,ML,234,140.4,,198.9,85,,159.12,Percent of total billed charges,85% of total billed charges,0.98,136.6,,4.224,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.98,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,82.25,35.15,,9.728,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,9.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.92,38,,71.136,percent of total billed charges,38% of total billed charges,74.76,31.95,,12.176,percent of total billed charges,31.95% of total billed charges,0.98,198.9,
rivaroxaban 10 mg Tab UD [FMC],2583656,CDM,250,RC,,,OUTPATIENT,1,EA,43.33,25.998,,36.83,85,,29.464,Percent of total billed charges,85% of total billed charges,21.67,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.67,50,,0.8,percent of total billed charges,50% of total billed charges,13.84,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,13.84,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.47,38,,13.176,percent of total billed charges,38% of total billed charges,17.33,40,,11.52,percent of total billed charges,40% of total billed charges,13.84,36.83,
linezolid 600 mg Tab [FMC],2583680,CDM,250,RC,,,OUTPATIENT,1,EA,485.09,291.054,,412.33,85,,329.864,Percent of total billed charges,85% of total billed charges,242.55,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,242.55,50,,44.8,percent of total billed charges,50% of total billed charges,154.99,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,154.99,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,184.33,38,,147.464,percent of total billed charges,38% of total billed charges,194.04,40,,11.52,percent of total billed charges,40% of total billed charges,154.99,412.33,
linezolid 600 mg Tab [FMC],2583680,CDM,250,RC,,,OUTPATIENT,1,EA,594.75,356.85,,505.54,85,,404.432,Percent of total billed charges,85% of total billed charges,297.38,50,,44.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,297.38,50,,16.8,percent of total billed charges,50% of total billed charges,190.02,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,190.02,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,226.01,38,,180.808,percent of total billed charges,38% of total billed charges,237.9,40,,9.6,percent of total billed charges,40% of total billed charges,190.02,505.54,
linezolid 600 mg Tab [FMC],2583680,CDM,250,RC,,,OUTPATIENT,1,EA,596.93,358.158,,507.39,85,,405.912,Percent of total billed charges,85% of total billed charges,298.47,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,298.47,50,,35.6,percent of total billed charges,50% of total billed charges,190.72,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,190.72,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,226.83,38,,181.464,percent of total billed charges,38% of total billed charges,238.77,40,,11.2,percent of total billed charges,40% of total billed charges,190.72,507.39,
linezolid 600 mg Tab [FMC] -  - Inpatient - FMC HOSP - Active - 00009-5135-02,2583680,CDM,250,RC,,,OUTPATIENT,1,EA,27.21,16.326,,23.13,85,,18.504,Percent of total billed charges,85% of total billed charges,13.61,50,,35.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.61,50,,4,percent of total billed charges,50% of total billed charges,8.69,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,8.69,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.34,38,,8.272,percent of total billed charges,38% of total billed charges,10.88,40,,11.52,percent of total billed charges,40% of total billed charges,8.69,23.13,
linezolid 600 mg Tab [FMC],2583680,CDM,250,RC,,,OUTPATIENT,1,EA,596.9,358.14,,507.37,85,,405.896,Percent of total billed charges,85% of total billed charges,298.45,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,298.45,50,,18,percent of total billed charges,50% of total billed charges,190.71,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,190.71,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,226.82,38,,181.456,percent of total billed charges,38% of total billed charges,238.76,40,,11.52,percent of total billed charges,40% of total billed charges,190.71,507.37,
linezolid 600 mg Tab [FMC],2583680,CDM,250,RC,,,OUTPATIENT,1,EA,24.51,14.706,,20.83,85,,16.664,Percent of total billed charges,85% of total billed charges,12.26,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.26,50,,13.6,percent of total billed charges,50% of total billed charges,7.83,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,7.83,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.31,38,,7.448,percent of total billed charges,38% of total billed charges,9.8,40,,11.52,percent of total billed charges,40% of total billed charges,7.83,20.83,
sodium nitrite-sodium thiosulfate 30 mg-250 mg/mL Sol [FMC],2583722,CDM,250,RC,,,OUTPATIENT,60,ML,663,397.8,,563.55,85,,450.84,Percent of total billed charges,85% of total billed charges,331.5,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,331.5,50,,12.352,percent of total billed charges,50% of total billed charges,211.83,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,211.83,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,251.94,38,,201.552,percent of total billed charges,38% of total billed charges,265.2,40,,12.8,percent of total billed charges,40% of total billed charges,211.83,563.55,
niCARdipine 20 mg/200 mL-NaCl 0.86% IV Sol [FMC],2583730,CDM,250,RC,,,OUTPATIENT,200,ML,396.44,237.864,,336.97,85,,269.576,Percent of total billed charges,85% of total billed charges,198.22,50,,12.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,198.22,50,,2.4,percent of total billed charges,50% of total billed charges,126.66,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,126.66,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.65,38,,120.52,percent of total billed charges,38% of total billed charges,158.58,40,,7.04,percent of total billed charges,40% of total billed charges,126.66,336.97,
niCARdipine 20 mg/200 mL-NaCl 0.86% IV Sol [FMC],2583730,CDM,250,RC,,,OUTPATIENT,200,ML,396.44,237.864,,336.97,85,,269.576,Percent of total billed charges,85% of total billed charges,198.22,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,198.22,50,,2,percent of total billed charges,50% of total billed charges,126.66,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,126.66,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.65,38,,120.52,percent of total billed charges,38% of total billed charges,158.58,40,,6.72,percent of total billed charges,40% of total billed charges,126.66,336.97,
niCARdipine 20 mg/200 mL-NaCl 0.86% IV Sol [FMC],2583730,CDM,250,RC,,,OUTPATIENT,200,ML,226.98,136.188,,192.93,85,,154.344,Percent of total billed charges,85% of total billed charges,113.49,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,113.49,50,,0.4,percent of total billed charges,50% of total billed charges,72.52,31.95,,85.2,percent of total billed charges,31.95% of total billed charges,72.52,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,86.25,38,,69,percent of total billed charges,38% of total billed charges,90.79,40,,77.448,percent of total billed charges,40% of total billed charges,72.52,192.93,
olanzapine 10mg Soln  [FMC],2583748,CDM,250,RC,,,OUTPATIENT,1,ML,190.32,114.192,,161.77,85,,129.416,Percent of total billed charges,85% of total billed charges,95.16,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,95.16,50,,11.6,percent of total billed charges,50% of total billed charges,60.81,31.95,,85.2,percent of total billed charges,31.95% of total billed charges,60.81,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,72.32,38,,57.856,percent of total billed charges,38% of total billed charges,76.13,40,,77.448,percent of total billed charges,40% of total billed charges,60.81,161.77,
olanzapine 10mg Soln  [FMC],2583748,CDM,250,RC,,,OUTPATIENT,1,ML,134.88,80.928,,114.65,85,,91.72,Percent of total billed charges,85% of total billed charges,67.44,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67.44,50,,12.8,percent of total billed charges,50% of total billed charges,43.09,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,43.09,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,51.25,38,,41,percent of total billed charges,38% of total billed charges,53.95,40,,42.176,percent of total billed charges,40% of total billed charges,43.09,114.65,
olanzapine 10mg Soln  [FMC],2583748,CDM,250,RC,,,OUTPATIENT,1,ML,134.88,80.928,,114.65,85,,91.72,Percent of total billed charges,85% of total billed charges,67.44,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67.44,50,,17.6,percent of total billed charges,50% of total billed charges,43.09,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,43.09,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,51.25,38,,41,percent of total billed charges,38% of total billed charges,53.95,40,,42.176,percent of total billed charges,40% of total billed charges,43.09,114.65,
olanzapine 10mg Soln  [FMC],2583748,CDM,250,RC,,,OUTPATIENT,1,ML,146.97,88.182,,124.92,85,,99.936,Percent of total billed charges,85% of total billed charges,73.49,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.49,50,,1.6,percent of total billed charges,50% of total billed charges,46.96,31.95,,144.536,percent of total billed charges,31.95% of total billed charges,46.96,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.85,38,,44.68,percent of total billed charges,38% of total billed charges,58.79,40,,131.376,percent of total billed charges,40% of total billed charges,46.96,124.92,
tranexamic acid 100 mg/mL Sol [FMC],2583763,CDM,250,RC,,,OUTPATIENT,10,ML,81.19,48.714,,69.01,85,,55.208,Percent of total billed charges,85% of total billed charges,40.6,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.6,50,,5.72,percent of total billed charges,50% of total billed charges,25.94,31.95,,144.536,percent of total billed charges,31.95% of total billed charges,25.94,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.85,38,,24.68,percent of total billed charges,38% of total billed charges,32.48,40,,131.376,percent of total billed charges,40% of total billed charges,25.94,69.01,
tranexamic acid 100 mg/mL Sol [FMC],2583763,CDM,250,RC,,,OUTPATIENT,10,ML,46.8,28.08,,39.78,85,,31.824,Percent of total billed charges,85% of total billed charges,23.4,50,,5.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.4,50,,4.8,percent of total billed charges,50% of total billed charges,14.95,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,14.95,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.78,38,,14.224,percent of total billed charges,38% of total billed charges,18.72,40,,42.176,percent of total billed charges,40% of total billed charges,14.95,39.78,
tranexamic acid 100 mg/mL Sol [FMC],2583763,CDM,250,RC,,,OUTPATIENT,10,ML,81.9,49.14,,69.62,85,,55.696,Percent of total billed charges,85% of total billed charges,40.95,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.95,50,,4.8,percent of total billed charges,50% of total billed charges,26.17,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,26.17,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.12,38,,24.896,percent of total billed charges,38% of total billed charges,32.76,40,,42.176,percent of total billed charges,40% of total billed charges,26.17,69.62,
tranexamic acid 100 mg/mL Sol [FMC],2583763,CDM,250,RC,,,OUTPATIENT,10,ML,28.28,16.968,,24.04,85,,19.232,Percent of total billed charges,85% of total billed charges,14.14,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.14,50,,4.8,percent of total billed charges,50% of total billed charges,9.04,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,9.04,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.75,38,,8.6,percent of total billed charges,38% of total billed charges,11.31,40,,42.176,percent of total billed charges,40% of total billed charges,9.04,24.04,
tranexamic acid 100 mg/mL Sol [FMC],2583763,CDM,250,RC,,,OUTPATIENT,10,ML,44.85,26.91,,38.12,85,,30.496,Percent of total billed charges,85% of total billed charges,22.43,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.43,50,,6,percent of total billed charges,50% of total billed charges,14.33,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,14.33,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.04,38,,13.632,percent of total billed charges,38% of total billed charges,17.94,40,,42.176,percent of total billed charges,40% of total billed charges,14.33,38.12,
hydrocodone-acetaminophen 5 mg-325 mg Tab [FMC],2583771,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.984,percent of total billed charges,50% of total billed charges,1.28,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,42.176,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 5 mg-325 mg Tab [FMC],2583771,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,5.984,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.4,percent of total billed charges,50% of total billed charges,1.28,31.95,,46.4,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,42.176,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 5 mg-325 mg Tab [FMC],2583771,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.4,percent of total billed charges,50% of total billed charges,1.28,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,216,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 5 mg-325 mg Tab [FMC],2583771,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.4,percent of total billed charges,50% of total billed charges,1.28,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,216,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 5 mg-325 mg Tab [FMC],2583771,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.4,percent of total billed charges,50% of total billed charges,1.28,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,216,percent of total billed charges,40% of total billed charges,1.28,3.4,
eptifibatide 0.75 mg/mL IV Sol [FMC],2583789,CDM,250,RC,J1327,HCPCS,OUTPATIENT,100,ML,1663.96,998.376,,1414.37,85,,1131.496,Percent of total billed charges,85% of total billed charges,34.66,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.66,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,584.88,35.15,,18.4,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,632.3,38,,505.84,percent of total billed charges,38% of total billed charges,531.64,31.95,,23.04,percent of total billed charges,31.95% of total billed charges,7.86,1414.37,
Eptifibatide Premix Additive [FMC],2583789,CDM,250,RC,J1327,HCPCS,OUTPATIENT,100,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,34.66,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.66,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,74.128,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,92.8,percent of total billed charges,31.95% of total billed charges,3.83,34.66,
eptifibatide 0.75 mg/mL IV Sol [FMC],2583789,CDM,250,RC,J1327,HCPCS,OUTPATIENT,100,ML,2291.25,1374.75,,1947.56,85,,1558.048,Percent of total billed charges,85% of total billed charges,34.66,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.66,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,805.37,35.15,,306.72,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,306.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,870.68,38,,696.544,percent of total billed charges,38% of total billed charges,732.05,31.95,,384,percent of total billed charges,31.95% of total billed charges,7.86,1947.56,
hydrocodone-acetaminophen 7.5 mg-325 mg Tab [FMC],2583797,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,160.008,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,160.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,200.32,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 7.5 mg-325 mg Tab [FMC],2583797,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4,percent of total billed charges,50% of total billed charges,1.28,31.95,,639,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,639,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,800,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 7.5 mg-325 mg Tab [FMC],2583797,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.4,percent of total billed charges,50% of total billed charges,1.28,31.95,,407.744,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,370.624,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 7.5 mg-325 mg Tab [FMC],2583797,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,476.696,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,476.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,596.8,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 7.5 mg-325 mg Tab [FMC],2583797,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,80.8,percent of total billed charges,50% of total billed charges,1.28,31.95,,1661.4,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1661.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,2080,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 7.5 mg-325 mg Tab [FMC],2583797,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,80.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,5.2,percent of total billed charges,50% of total billed charges,1.28,31.95,,602.96,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,602.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,754.88,percent of total billed charges,40% of total billed charges,1.28,3.4,
hydrocodone-acetaminophen 7.5 mg-325 mg Tab [FMC],2583797,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,18,percent of total billed charges,50% of total billed charges,1.28,31.95,,215.728,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,215.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,270.08,percent of total billed charges,40% of total billed charges,1.28,3.4,
bacitracin topical UD 500 units/g Oin [FMC],2583813,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,0.8,percent of total billed charges,50% of total billed charges,1.92,31.95,,236.432,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,236.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,296,percent of total billed charges,40% of total billed charges,1.92,5.1,
RHo (D) immune globulin 300 mcg Sol [FMC],2583821,CDM,250,RC,J2790,HCPCS,OUTPATIENT,1,EA,413.4,248.04,,351.39,85,,281.112,Percent of total billed charges,85% of total billed charges,116.15,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,116.15,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,145.31,35.15,,314.392,fee schedule,35.15% of LA custom fee schedule,132.08,31.95,,314.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,157.09,38,,125.672,percent of total billed charges,38% of total billed charges,132.08,31.95,,393.6,Fee Schedule,31.95% of LA custom fee schedule,116.15,351.39,
alteplase 2 mg REC [FMC],2583823,CDM,250,RC,J2997,HCPCS,OUTPATIENT,1,EA,655.01,393.006,,556.76,85,,445.408,Percent of total billed charges,85% of total billed charges,133.98,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,133.98,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,230.24,35.15,,281.16,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,281.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,248.9,38,,199.12,percent of total billed charges,38% of total billed charges,209.28,31.95,,352,percent of total billed charges,31.95% of total billed charges,7.86,556.76,
cephalexin 250 mg Cap [FMC],2583839,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,2,percent of total billed charges,50% of total billed charges,0.96,31.95,,843.6,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,766.8,percent of total billed charges,40% of total billed charges,0.96,2.55,
cephalexin 250 mg Cap [FMC],2583839,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,188.8,percent of total billed charges,40% of total billed charges,0.96,2.55,
sugammadex 100 mg/mL Inj Sol [FMC],2583862,CDM,250,RC,,,OUTPATIENT,2,ML,450.14,270.084,,382.62,85,,306.096,Percent of total billed charges,85% of total billed charges,225.07,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,225.07,50,,11.6,percent of total billed charges,50% of total billed charges,143.82,31.95,,325.888,percent of total billed charges,31.95% of total billed charges,143.82,31.95,,325.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,171.05,38,,136.84,percent of total billed charges,38% of total billed charges,180.06,40,,408,percent of total billed charges,40% of total billed charges,143.82,382.62,
Multiple Vitamins with Minerals Oral Liq 240 mL [FMC],2583870,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,480,percent of total billed charges,40% of total billed charges,0.96,2.55,
vancomycin 125 mg Cap [FMC],2583912,CDM,250,RC,,,OUTPATIENT,1,EA,113.1,67.86,,96.14,85,,76.912,Percent of total billed charges,85% of total billed charges,56.55,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.55,50,,42.4,percent of total billed charges,50% of total billed charges,36.14,31.95,,325.888,percent of total billed charges,31.95% of total billed charges,36.14,31.95,,325.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.98,38,,34.384,percent of total billed charges,38% of total billed charges,45.24,40,,408,percent of total billed charges,40% of total billed charges,36.14,96.14,
vancomycin 125 mg Cap [FMC],2583912,CDM,250,RC,,,OUTPATIENT,1,EA,113.1,67.86,,96.14,85,,76.912,Percent of total billed charges,85% of total billed charges,56.55,50,,42.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.55,50,,3.6,percent of total billed charges,50% of total billed charges,36.14,31.95,,655.36,percent of total billed charges,31.95% of total billed charges,36.14,31.95,,655.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.98,38,,34.384,percent of total billed charges,38% of total billed charges,45.24,40,,820.48,percent of total billed charges,40% of total billed charges,36.14,96.14,
vancomycin hcl 125mg Oral Cap [FMC]v,2583912,CDM,250,RC,,,OUTPATIENT,1,EA,101.81,61.086,,86.54,85,,69.232,Percent of total billed charges,85% of total billed charges,50.91,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.91,50,,3.6,percent of total billed charges,50% of total billed charges,32.53,31.95,,575.104,percent of total billed charges,31.95% of total billed charges,32.53,31.95,,575.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.69,38,,30.952,percent of total billed charges,38% of total billed charges,40.72,40,,720,percent of total billed charges,40% of total billed charges,32.53,86.54,
vancomycin 125 mg Cap [FMC],2583912,CDM,250,RC,,,OUTPATIENT,1,EA,101.74,61.044,,86.48,85,,69.184,Percent of total billed charges,85% of total billed charges,50.87,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.87,50,,3.6,percent of total billed charges,50% of total billed charges,32.51,31.95,,1451.808,percent of total billed charges,31.95% of total billed charges,32.51,31.95,,1451.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.66,38,,30.928,percent of total billed charges,38% of total billed charges,40.7,40,,1817.6,percent of total billed charges,40% of total billed charges,32.51,86.48,
vancomycin 125 mg Cap [FMC],2583912,CDM,250,RC,,,OUTPATIENT,1,EA,101.74,61.044,,86.48,85,,69.184,Percent of total billed charges,85% of total billed charges,50.87,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.87,50,,3.6,percent of total billed charges,50% of total billed charges,32.51,31.95,,177.64,percent of total billed charges,31.95% of total billed charges,32.51,31.95,,177.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.66,38,,30.928,percent of total billed charges,38% of total billed charges,40.7,40,,222.4,percent of total billed charges,40% of total billed charges,32.51,86.48,
vancomycin 125 mg Cap [FMC],2583912,CDM,250,RC,,,OUTPATIENT,1,EA,101.74,61.044,,86.48,85,,69.184,Percent of total billed charges,85% of total billed charges,50.87,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.87,50,,0.4,percent of total billed charges,50% of total billed charges,32.51,31.95,,1256.016,percent of total billed charges,31.95% of total billed charges,32.51,31.95,,1256.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.66,38,,30.928,percent of total billed charges,38% of total billed charges,40.7,40,,1572.48,percent of total billed charges,40% of total billed charges,32.51,86.48,
Pharmacy Compound 60 mL Soln,2583920,CDM,250,RC,,,OUTPATIENT,60,ML,82.06,49.236,,69.75,85,,55.8,Percent of total billed charges,85% of total billed charges,41.03,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,41.03,50,,1.2,percent of total billed charges,50% of total billed charges,26.22,31.95,,268.888,percent of total billed charges,31.95% of total billed charges,26.22,31.95,,268.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.18,38,,24.944,percent of total billed charges,38% of total billed charges,32.82,40,,336.64,percent of total billed charges,40% of total billed charges,26.22,69.75,
bicalutamide 50 mg Tab [FMC],2583938,CDM,250,RC,,,OUTPATIENT,1,EA,7.92,4.752,,6.73,85,,5.384,Percent of total billed charges,85% of total billed charges,3.96,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.96,50,,2,percent of total billed charges,50% of total billed charges,2.53,31.95,,741.24,percent of total billed charges,31.95% of total billed charges,2.53,31.95,,741.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.01,38,,2.408,percent of total billed charges,38% of total billed charges,3.17,40,,928,percent of total billed charges,40% of total billed charges,2.53,6.73,
bicalutamide 50 mg Tab [FMC],2583938,CDM,250,RC,,,OUTPATIENT,1,EA,59.65,35.79,,50.7,85,,40.56,Percent of total billed charges,85% of total billed charges,29.83,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.83,50,,1.6,percent of total billed charges,50% of total billed charges,19.06,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,19.06,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.67,38,,18.136,percent of total billed charges,38% of total billed charges,23.86,40,,204.48,percent of total billed charges,40% of total billed charges,19.06,50.7,
bicalutamide 50 mg Tab [FMC],2583938,CDM,250,RC,,,OUTPATIENT,1,EA,60.23,36.138,,51.2,85,,40.96,Percent of total billed charges,85% of total billed charges,30.12,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.12,50,,21.6,percent of total billed charges,50% of total billed charges,19.24,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,19.24,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.89,38,,18.312,percent of total billed charges,38% of total billed charges,24.09,40,,204.48,percent of total billed charges,40% of total billed charges,19.24,51.2,
bicalutamide 50 mg Tab [FMC],2583938,CDM,250,RC,,,OUTPATIENT,1,EA,59.65,35.79,,50.7,85,,40.56,Percent of total billed charges,85% of total billed charges,29.83,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.83,50,,22.4,percent of total billed charges,50% of total billed charges,19.06,31.95,,687.312,percent of total billed charges,31.95% of total billed charges,19.06,31.95,,687.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.67,38,,18.136,percent of total billed charges,38% of total billed charges,23.86,40,,860.48,percent of total billed charges,40% of total billed charges,19.06,50.7,
"emollients, Top Lotion [FMC]",2583953,CDM,250,RC,,,OUTPATIENT,180,EA,8.83,5.298,,7.51,85,,6.008,Percent of total billed charges,85% of total billed charges,4.42,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.42,50,,22.4,percent of total billed charges,50% of total billed charges,2.82,31.95,,851.152,percent of total billed charges,31.95% of total billed charges,2.82,31.95,,851.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.36,38,,2.688,percent of total billed charges,38% of total billed charges,3.53,40,,1065.6,percent of total billed charges,40% of total billed charges,2.82,7.51,
"emollients, Top Lotion [FMC]",2583953,CDM,250,RC,,,OUTPATIENT,180,EA,8.56,5.136,,7.28,85,,5.824,Percent of total billed charges,85% of total billed charges,4.28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.28,50,,22.4,percent of total billed charges,50% of total billed charges,2.73,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,2.73,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.25,38,,2.6,percent of total billed charges,38% of total billed charges,3.42,40,,204.48,percent of total billed charges,40% of total billed charges,2.73,7.28,
levETIRAcetam 100 mg/mL Oral Liq [FMC],2583961,CDM,250,RC,,,OUTPATIENT,5,ML,11.84,7.104,,10.06,85,,8.048,Percent of total billed charges,85% of total billed charges,5.92,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.92,50,,22.4,percent of total billed charges,50% of total billed charges,3.78,31.95,,558.488,percent of total billed charges,31.95% of total billed charges,3.78,31.95,,558.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.5,38,,3.6,percent of total billed charges,38% of total billed charges,4.74,40,,699.2,percent of total billed charges,40% of total billed charges,3.78,10.06,
levETIRAcetam 100 mg/mL Oral Liq [FMC],2583961,CDM,250,RC,,,OUTPATIENT,5,ML,10.57,6.342,,8.98,85,,7.184,Percent of total billed charges,85% of total billed charges,5.29,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.29,50,,22.4,percent of total billed charges,50% of total billed charges,3.38,31.95,,193.744,percent of total billed charges,31.95% of total billed charges,3.38,31.95,,193.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.02,38,,3.216,percent of total billed charges,38% of total billed charges,4.23,40,,242.56,percent of total billed charges,40% of total billed charges,3.38,8.98,
methylnaltrexone bromide 12mg/0.6ml Sol [FMC],2583979,CDM,250,RC,J2212,HCPCS,OUTPATIENT,0.6,EA,566.05,339.63,,481.14,85,,384.912,Percent of total billed charges,85% of total billed charges,1.9,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.9,136.6,,4.304,fee schedule,136.60% of BCBS custom fee schedule,198.97,35.15,,1171.928,fee schedule,35.15% of LA custom fee schedule,180.85,31.95,,1171.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,215.1,38,,172.08,percent of total billed charges,38% of total billed charges,180.85,31.95,,1467.2,Fee Schedule,31.95% of LA custom fee schedule,1.9,481.14,
methylnaltrexone bromide 12mg/0.6ml Sol [FMC],2583979,CDM,250,RC,J2212,HCPCS,OUTPATIENT,0.6,EA,425.09,255.054,,361.33,85,,289.064,Percent of total billed charges,85% of total billed charges,1.9,136.6,,4.304,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.9,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,149.42,35.15,,281.16,fee schedule,35.15% of LA custom fee schedule,135.82,31.95,,281.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,161.53,38,,129.224,percent of total billed charges,38% of total billed charges,135.82,31.95,,352,Fee Schedule,31.95% of LA custom fee schedule,1.9,361.33,
methylnaltrexone bromide 12mg/0.6ml Sol [FMC],2583979,CDM,250,RC,J2212,HCPCS,OUTPATIENT,0.6,EA,566.05,339.63,,481.14,85,,384.912,Percent of total billed charges,85% of total billed charges,1.9,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.9,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,198.97,35.15,,215.728,fee schedule,35.15% of LA custom fee schedule,180.85,31.95,,215.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,215.1,38,,172.08,percent of total billed charges,38% of total billed charges,180.85,31.95,,270.08,Fee Schedule,31.95% of LA custom fee schedule,1.9,481.14,
filgrastim 480 mcg/0.8 mL Sol[FMC],2583987,CDM,250,RC,J1442,HCPCS,OUTPATIENT,0.8,ML,1984.32,1190.592,,1686.67,85,,1349.336,Percent of total billed charges,85% of total billed charges,0.26,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.26,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,697.49,35.15,,153.36,fee schedule,35.15% of LA custom fee schedule,633.99,31.95,,153.36,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,754.04,38,,603.232,percent of total billed charges,38% of total billed charges,633.99,31.95,,192,Fee Schedule,31.95% of LA custom fee schedule,0.26,1686.67,
methylprednisolone sodium succinate 1000 mg Sol [FMC],2584035,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,EA,251.2,150.72,,213.52,85,,170.816,Percent of total billed charges,85% of total billed charges,0.41,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,4.224,fee schedule,136.60% of BCBS custom fee schedule,88.3,35.15,,361.928,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,361.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95.46,38,,76.368,percent of total billed charges,38% of total billed charges,80.26,31.95,,453.12,percent of total billed charges,31.95% of total billed charges,0.41,213.52,
lidocaine topical 5% rectal Crm [FMC],2584043,CDM,250,RC,,,OUTPATIENT,30,EA,70.2,42.12,,59.67,85,,47.736,Percent of total billed charges,85% of total billed charges,35.1,50,,4.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.1,50,,2.4,percent of total billed charges,50% of total billed charges,22.43,31.95,,93.296,percent of total billed charges,31.95% of total billed charges,22.43,31.95,,93.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.68,38,,21.344,percent of total billed charges,38% of total billed charges,28.08,40,,116.8,percent of total billed charges,40% of total billed charges,22.43,59.67,
methylprednisolone sodium succinate 500mg Sol [FMC],2584050,CDM,250,RC,J2919,HCPCS,OUTPATIENT,1,EA,90.16,54.096,,76.64,85,,61.312,Percent of total billed charges,85% of total billed charges,0.41,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,31.69,35.15,,984.2,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,75.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.26,38,,27.408,percent of total billed charges,38% of total billed charges,28.81,31.95,,894.6,percent of total billed charges,31.95% of total billed charges,0.41,76.64,
purified water-menthol oral rinse Sol 473 mL [FMC],2584076,CDM,250,RC,,,OUTPATIENT,473,ML,16.51,9.906,,14.03,85,,11.224,Percent of total billed charges,85% of total billed charges,8.26,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.26,50,,3.6,percent of total billed charges,50% of total billed charges,5.27,31.95,,98.424,percent of total billed charges,31.95% of total billed charges,5.27,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.27,38,,5.016,percent of total billed charges,38% of total billed charges,6.6,40,,89.464,percent of total billed charges,40% of total billed charges,5.27,14.03,
simethicone 80 mg Che UD [FMC],2584092,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12,percent of total billed charges,50% of total billed charges,0.96,31.95,,655.36,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,655.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,820.48,percent of total billed charges,40% of total billed charges,0.96,2.55,
simethicone 80 mg Che UD [FMC],2584092,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12,percent of total billed charges,50% of total billed charges,0.96,31.95,,499.696,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,499.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,625.6,percent of total billed charges,40% of total billed charges,0.96,2.55,
simethicone 80 mg Che UD [FMC],2584092,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,12,percent of total billed charges,50% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,524.16,percent of total billed charges,40% of total billed charges,0.96,2.55,
simethicone 80 mg Che UD [FMC],2584092,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,38.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,74.88,percent of total billed charges,40% of total billed charges,0.96,2.55,
BCG 50 mg REC [FMC],2584100,CDM,250,RC,J9030,HCPCS,OUTPATIENT,1,EA,566.09,339.654,,481.18,85,,384.944,Percent of total billed charges,85% of total billed charges,4.38,136.6,,38.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.38,136.6,,36.8,fee schedule,136.60% of BCBS custom fee schedule,198.98,35.15,,42.944,fee schedule,35.15% of LA custom fee schedule,180.87,31.95,,42.944,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,215.11,38,,172.088,percent of total billed charges,38% of total billed charges,180.87,31.95,,53.76,Fee Schedule,31.95% of LA custom fee schedule,4.38,481.18,
magnesium sulfate 2 g/50 mL-sterile water Sol [FMC],2584167,CDM,250,RC,J3475,HCPCS,OUTPATIENT,50,ML,62.56,37.536,,53.18,85,,42.544,Percent of total billed charges,85% of total billed charges,1.15,136.6,,36.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,123.2,fee schedule,136.60% of BCBS custom fee schedule,21.99,35.15,,59.04,percent of total billed charges,35.15% of total billed charges,7.86,31.95,,59.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.77,38,,19.016,percent of total billed charges,38% of total billed charges,19.99,31.95,,73.92,percent of total billed charges,31.95% of total billed charges,1.15,53.18,
magnesium sulfate 2 g/50 mL-sterile water Sol [FMC],2584167,CDM,250,RC,J3475,HCPCS,OUTPATIENT,50,ML,62.56,37.536,,53.18,85,,42.544,Percent of total billed charges,85% of total billed charges,1.15,136.6,,123.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,45.36,fee schedule,136.60% of BCBS custom fee schedule,21.99,35.15,,150.808,percent of total billed charges,35.15% of total billed charges,77.32,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.77,38,,19.016,percent of total billed charges,38% of total billed charges,19.99,31.95,,188.8,percent of total billed charges,31.95% of total billed charges,1.15,77.32,
magnesium sulfate 2 g/50 mL-sterile water Sol [FMC],2584167,CDM,250,RC,J3475,HCPCS,OUTPATIENT,50,ML,57.72,34.632,,49.06,85,,39.248,Percent of total billed charges,85% of total billed charges,1.15,136.6,,45.36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,20.29,35.15,,74.128,percent of total billed charges,35.15% of total billed charges,77.32,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.93,38,,17.544,percent of total billed charges,38% of total billed charges,18.44,31.95,,92.8,percent of total billed charges,31.95% of total billed charges,1.15,77.32,
magnesium sulfate 2 g/50 mL-sterile water Sol [FMC],2584167,CDM,250,RC,J3475,HCPCS,OUTPATIENT,50,ML,65.33,39.198,,55.53,85,,44.424,Percent of total billed charges,85% of total billed charges,1.15,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,22.96,35.15,,58.28,percent of total billed charges,35.15% of total billed charges,77.64,31.95,,58.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.83,38,,19.864,percent of total billed charges,38% of total billed charges,20.87,31.95,,72.96,percent of total billed charges,31.95% of total billed charges,1.15,77.64,
famotidine 10 mg/mL Inj Sol [FMC],2584183,CDM,250,RC,S0028,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.39,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,29.648,percent of total billed charges,35.15% of total billed charges,77.96,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,37.12,percent of total billed charges,31.95% of total billed charges,1.39,77.96,
famotidine 10 mg/mL Inj Sol [FMC],2584183,CDM,250,RC,S0028,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.39,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,85.624,percent of total billed charges,35.15% of total billed charges,79.24,31.95,,85.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,107.2,percent of total billed charges,31.95% of total billed charges,1.39,79.24,
famotidine 10 mg/mL Inj Sol [FMC],2584183,CDM,250,RC,S0028,HCPCS,OUTPATIENT,2,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.39,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.39,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,43.456,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,54.4,percent of total billed charges,31.95% of total billed charges,1.39,10.2,
citric acid-sodium citrate 334 mg-500 mg/5 mL Sol [FMC],2584209,CDM,250,RC,,,OUTPATIENT,30,ML,8.87,5.322,,7.54,85,,6.032,Percent of total billed charges,85% of total billed charges,4.44,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.44,50,,24.8,percent of total billed charges,50% of total billed charges,2.83,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,2.83,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.37,38,,2.696,percent of total billed charges,38% of total billed charges,3.55,40,,152,percent of total billed charges,40% of total billed charges,2.83,7.54,
citric acid-sodium citrate 334 mg-500 mg/5 mL Sol [FMC],2584209,CDM,250,RC,,,OUTPATIENT,30,ML,3.46,2.076,,2.94,85,,2.352,Percent of total billed charges,85% of total billed charges,1.73,50,,24.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.73,50,,4.4,percent of total billed charges,50% of total billed charges,1.11,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,1.11,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.31,38,,1.048,percent of total billed charges,38% of total billed charges,1.38,40,,53.76,percent of total billed charges,40% of total billed charges,1.11,2.94,
ethyl chloride topical 100% Spray [FMC],2584217,CDM,250,RC,,,OUTPATIENT,103.5,UN,113.75,68.25,,96.69,85,,77.352,Percent of total billed charges,85% of total billed charges,56.88,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.88,50,,4.4,percent of total billed charges,50% of total billed charges,36.34,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,36.34,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.23,38,,34.584,percent of total billed charges,38% of total billed charges,45.5,40,,53.76,percent of total billed charges,40% of total billed charges,36.34,96.69,
ethyl chloride topical 100% Spray [FMC],2584217,CDM,250,RC,,,OUTPATIENT,103.5,UN,120.25,72.15,,102.21,85,,81.768,Percent of total billed charges,85% of total billed charges,60.13,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,60.13,50,,4.4,percent of total billed charges,50% of total billed charges,38.42,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,38.42,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.7,38,,36.56,percent of total billed charges,38% of total billed charges,48.1,40,,112,percent of total billed charges,40% of total billed charges,38.42,102.21,
prothrombin complex - REC [FMC],2584225,CDM,250,RC,J7168,HCPCS,OUTPATIENT,1,EA,3191.76,1915.056,,2713,85,,2170.4,Percent of total billed charges,85% of total billed charges,4.4,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.4,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,1121.9,35.15,,42.944,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1212.87,38,,970.296,percent of total billed charges,38% of total billed charges,1019.77,31.95,,53.76,percent of total billed charges,31.95% of total billed charges,4.4,2713,
iron sucrose 20 mg/mL Sol [FMC],2584233,CDM,250,RC,J1756,HCPCS,OUTPATIENT,5,ML,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,0.31,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.31,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,68.54,35.15,,70.544,fee schedule,35.15% of LA custom fee schedule,62.3,31.95,,70.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,74.1,38,,59.28,percent of total billed charges,38% of total billed charges,62.3,31.95,,88.32,Fee Schedule,31.95% of LA custom fee schedule,0.31,165.75,
permethrin topical 5% Cre [FMC],2584241,CDM,250,RC,,,OUTPATIENT,5,EA,33.52,20.112,,28.49,85,,22.792,Percent of total billed charges,85% of total billed charges,16.76,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.76,50,,6,percent of total billed charges,50% of total billed charges,10.71,31.95,,101.984,percent of total billed charges,31.95% of total billed charges,10.71,31.95,,101.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.74,38,,10.192,percent of total billed charges,38% of total billed charges,13.41,40,,127.68,percent of total billed charges,40% of total billed charges,10.71,28.49,
permethrin topical 5% Cre [FMC],2584241,CDM,250,RC,,,OUTPATIENT,5,EA,31.96,19.176,,27.17,85,,21.736,Percent of total billed charges,85% of total billed charges,15.98,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.98,50,,14.96,percent of total billed charges,50% of total billed charges,10.21,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,10.21,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.14,38,,9.712,percent of total billed charges,38% of total billed charges,12.78,40,,255.04,percent of total billed charges,40% of total billed charges,10.21,27.17,
orphenadrine 30 mg/mL Sol [FMC],2584266,CDM,250,RC,J2360,HCPCS,OUTPATIENT,1,ML,36.08,21.648,,30.67,85,,24.536,Percent of total billed charges,85% of total billed charges,7.02,136.6,,14.96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.02,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,12.68,35.15,,496.12,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,496.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.71,38,,10.968,percent of total billed charges,38% of total billed charges,11.53,31.95,,621.12,percent of total billed charges,31.95% of total billed charges,7.02,30.67,
orphenadrine 30 mg/mL Sol [FMC],2584266,CDM,250,RC,J2360,HCPCS,OUTPATIENT,1,ML,30.42,18.252,,25.86,85,,20.688,Percent of total billed charges,85% of total billed charges,7.02,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7.02,136.6,,17.76,fee schedule,136.60% of BCBS custom fee schedule,10.69,35.15,,496.12,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,496.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.56,38,,9.248,percent of total billed charges,38% of total billed charges,9.72,31.95,,621.12,percent of total billed charges,31.95% of total billed charges,7.02,25.86,
peramivir 10 mg/mL 200 mg Sol [FMC],2584282,CDM,250,RC,J2547,HCPCS,OUTPATIENT,1,ML,61.75,37.05,,52.49,85,,41.992,Percent of total billed charges,85% of total billed charges,2.34,136.6,,17.76,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.34,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,21.71,35.15,,418.672,fee schedule,35.15% of LA custom fee schedule,19.73,31.95,,418.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,23.47,38,,18.776,percent of total billed charges,38% of total billed charges,19.73,31.95,,524.16,Fee Schedule,31.95% of LA custom fee schedule,2.34,52.49,
peramivir 10 mg/mL 200 mg Sol [FMC],2584282,CDM,250,RC,J2547,HCPCS,OUTPATIENT,1,ML,51.46,30.876,,43.74,85,,34.992,Percent of total billed charges,85% of total billed charges,2.34,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.34,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,18.09,35.15,,1399.408,fee schedule,35.15% of LA custom fee schedule,16.44,31.95,,1399.408,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.55,38,,15.64,percent of total billed charges,38% of total billed charges,16.44,31.95,,1752,Fee Schedule,31.95% of LA custom fee schedule,2.34,43.74,
dexmedetomidine 4 mcg/mL-NaCl 0.9% Sol 100mL [FMC],2584290,CDM,250,RC,,,OUTPATIENT,50,ML,216.65,129.99,,184.15,85,,147.32,Percent of total billed charges,85% of total billed charges,108.33,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108.33,50,,24,percent of total billed charges,50% of total billed charges,69.22,31.95,,157.192,percent of total billed charges,31.95% of total billed charges,69.22,31.95,,157.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.33,38,,65.864,percent of total billed charges,38% of total billed charges,86.66,40,,196.8,percent of total billed charges,40% of total billed charges,69.22,184.15,
dexmedetomidine 4 mcg/mL-NaCl 0.9% Sol 50 mL [FMC],2584290,CDM,250,RC,,,OUTPATIENT,50,ML,216.65,129.99,,184.15,85,,147.32,Percent of total billed charges,85% of total billed charges,108.33,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108.33,50,,26.952,percent of total billed charges,50% of total billed charges,69.22,31.95,,943.168,percent of total billed charges,31.95% of total billed charges,69.22,31.95,,943.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.33,38,,65.864,percent of total billed charges,38% of total billed charges,86.66,40,,1180.8,percent of total billed charges,40% of total billed charges,69.22,184.15,
dexmedetomidine 4 mcg/mL-NaCl 0.9% Sol [FMC],2584290,CDM,250,RC,,,OUTPATIENT,50,ML,167.7,100.62,,142.55,85,,114.04,Percent of total billed charges,85% of total billed charges,83.85,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,83.85,50,,26.952,percent of total billed charges,50% of total billed charges,53.58,31.95,,943.168,percent of total billed charges,31.95% of total billed charges,53.58,31.95,,943.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.73,38,,50.984,percent of total billed charges,38% of total billed charges,67.08,40,,1180.8,percent of total billed charges,40% of total billed charges,53.58,142.55,
dexmedetomidine 4 mcg/mL-NaCl 0.9% Sol 50mL [FMC],2584290,CDM,250,RC,,,OUTPATIENT,50,ML,174.69,104.814,,148.49,85,,118.792,Percent of total billed charges,85% of total billed charges,87.35,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.35,50,,26.952,percent of total billed charges,50% of total billed charges,55.81,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,55.81,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.38,38,,53.104,percent of total billed charges,38% of total billed charges,69.88,40,,112,percent of total billed charges,40% of total billed charges,55.81,148.49,
Sodium Chloirde 0.9% IRR Sol 3000 mL [FMC],2584308,CDM,250,RC,,,OUTPATIENT,1,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,27.2,percent of total billed charges,50% of total billed charges,11.5,31.95,,167.416,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,167.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,209.6,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloirde 0.9% IRR Sol 3000 mL [FMC],2584308,CDM,250,RC,,,OUTPATIENT,1,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,5.6,percent of total billed charges,50% of total billed charges,11.5,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,192,percent of total billed charges,40% of total billed charges,11.5,30.6,
benzoin topical compound Swa,2584324,CDM,250,RC,,,OUTPATIENT,1,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,11.368,percent of total billed charges,50% of total billed charges,1.92,31.95,,167.416,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,167.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,209.6,percent of total billed charges,40% of total billed charges,1.92,5.1,
phytonadione 1 mg/0.5 mL Sol,2584365,CDM,250,RC,J3430,HCPCS,OUTPATIENT,1,ML,140.4,84.24,,119.34,85,,95.472,Percent of total billed charges,85% of total billed charges,4.48,136.6,,11.368,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.48,136.6,,26.952,fee schedule,136.60% of BCBS custom fee schedule,49.35,35.15,,81.792,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.35,38,,42.68,percent of total billed charges,38% of total billed charges,44.86,31.95,,102.4,percent of total billed charges,31.95% of total billed charges,4.48,119.34,
vitamin A & D topical 56 gm- Oin [FMC],2584381,CDM,250,RC,,,OUTPATIENT,42.5,EA,8.16,4.896,,6.94,85,,5.552,Percent of total billed charges,85% of total billed charges,4.08,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.08,50,,27.2,percent of total billed charges,50% of total billed charges,2.61,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,2.61,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.1,38,,2.48,percent of total billed charges,38% of total billed charges,3.26,40,,28.8,percent of total billed charges,40% of total billed charges,2.61,6.94,
vitamin A & D topical 56 gm- Oin [FMC],2584381,CDM,250,RC,,,OUTPATIENT,42.5,EA,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,16,percent of total billed charges,50% of total billed charges,1.92,31.95,,242.824,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,242.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,304,percent of total billed charges,40% of total billed charges,1.92,5.1,
vitamin A & D topical 56 gm- Oin [FMC],2584381,CDM,250,RC,,,OUTPATIENT,42.5,EA,8.64,5.184,,7.34,85,,5.872,Percent of total billed charges,85% of total billed charges,4.32,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.32,50,,2.8,percent of total billed charges,50% of total billed charges,2.76,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,2.76,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.28,38,,2.624,percent of total billed charges,38% of total billed charges,3.46,40,,160,percent of total billed charges,40% of total billed charges,2.76,7.34,
ropivacaine 0.5% 30 ml Sol [FMC],2584423,CDM,250,RC,J2795,HCPCS,OUTPATIENT,30,ML,110.06,66.036,,93.55,85,,74.84,Percent of total billed charges,85% of total billed charges,0.11,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,38.69,35.15,,25.56,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.82,38,,33.456,percent of total billed charges,38% of total billed charges,35.16,31.95,,32,percent of total billed charges,31.95% of total billed charges,0.11,93.55,
ropivacaine 0.5% 30 ml Sol [FMC],2584423,CDM,250,RC,J2795,HCPCS,OUTPATIENT,30,ML,122.85,73.71,,104.42,85,,83.536,Percent of total billed charges,85% of total billed charges,0.11,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,31.6,fee schedule,136.60% of BCBS custom fee schedule,43.18,35.15,,361.928,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,361.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.68,38,,37.344,percent of total billed charges,38% of total billed charges,39.25,31.95,,453.12,percent of total billed charges,31.95% of total billed charges,0.11,104.42,
"fat emulsion, intravenous 20% EMU [FMC]",2584449,CDM,250,RC,,,OUTPATIENT,250,ML,183.76,110.256,,156.2,85,,124.96,Percent of total billed charges,85% of total billed charges,91.88,50,,31.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,91.88,50,,23.2,percent of total billed charges,50% of total billed charges,58.71,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,58.71,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.83,38,,55.864,percent of total billed charges,38% of total billed charges,73.5,40,,108.8,percent of total billed charges,40% of total billed charges,58.71,156.2,
"fat emulsion, intravenous 20% EMU [FMC]",2584449,CDM,250,RC,,,OUTPATIENT,250,ML,171.75,103.05,,145.99,85,,116.792,Percent of total billed charges,85% of total billed charges,85.88,50,,23.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85.88,50,,36.4,percent of total billed charges,50% of total billed charges,54.87,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,54.87,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,65.27,38,,52.216,percent of total billed charges,38% of total billed charges,68.7,40,,224,percent of total billed charges,40% of total billed charges,54.87,145.99,
lacosamide 50 mg Tab [FMC],2584480,CDM,250,RC,,,OUTPATIENT,1,EA,45.66,27.396,,38.81,85,,31.048,Percent of total billed charges,85% of total billed charges,22.83,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.83,50,,19.24,percent of total billed charges,50% of total billed charges,14.59,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,14.59,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.35,38,,13.88,percent of total billed charges,38% of total billed charges,18.26,40,,22.4,percent of total billed charges,40% of total billed charges,14.59,38.81,
sacubitril-valsartan 24 mg-26 mg Tab [FMC],2584506,CDM,250,RC,,,OUTPATIENT,1,EA,23.91,14.346,,20.32,85,,16.256,Percent of total billed charges,85% of total billed charges,11.96,50,,19.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.96,50,,9.2,percent of total billed charges,50% of total billed charges,7.64,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,7.64,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.09,38,,7.272,percent of total billed charges,38% of total billed charges,9.56,40,,30.4,percent of total billed charges,40% of total billed charges,7.64,20.32,
sacubitril-valsartan 24 mg-26 mg Tab [FMC],2584506,CDM,250,RC,,,OUTPATIENT,1,EA,40.54,24.324,,34.46,85,,27.568,Percent of total billed charges,85% of total billed charges,20.27,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.27,50,,9.424,percent of total billed charges,50% of total billed charges,12.95,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,12.95,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.41,38,,12.328,percent of total billed charges,38% of total billed charges,16.22,40,,40,percent of total billed charges,40% of total billed charges,12.95,34.46,
memantine 14 mg ER [FMC],2584514,CDM,250,RC,,,OUTPATIENT,1,EA,41.84,25.104,,35.56,85,,28.448,Percent of total billed charges,85% of total billed charges,20.92,50,,9.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.92,50,,8.4,percent of total billed charges,50% of total billed charges,13.37,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,13.37,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.9,38,,12.72,percent of total billed charges,38% of total billed charges,16.74,40,,48,percent of total billed charges,40% of total billed charges,13.37,35.56,
memantine 14 mg ER [FMC],2584514,CDM,250,RC,,,OUTPATIENT,1,EA,41.84,25.104,,35.56,85,,28.448,Percent of total billed charges,85% of total billed charges,20.92,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.92,50,,5.6,percent of total billed charges,50% of total billed charges,13.37,31.95,,129.08,percent of total billed charges,31.95% of total billed charges,13.37,31.95,,129.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.9,38,,12.72,percent of total billed charges,38% of total billed charges,16.74,40,,161.6,percent of total billed charges,40% of total billed charges,13.37,35.56,
memantine 14 mg ER [FMC],2584514,CDM,250,RC,,,OUTPATIENT,1,EA,49.66,29.796,,42.21,85,,33.768,Percent of total billed charges,85% of total billed charges,24.83,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.83,50,,6.4,percent of total billed charges,50% of total billed charges,15.87,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,15.87,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.87,38,,15.096,percent of total billed charges,38% of total billed charges,19.86,40,,24,percent of total billed charges,40% of total billed charges,15.87,42.21,
acyclovir 50 mg/mL Sol 10 mL [FMC],2584517,CDM,250,RC,J0133,HCPCS,OUTPATIENT,10,ML,73.32,43.992,,62.32,85,,49.856,Percent of total billed charges,85% of total billed charges,0.08,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,25.77,35.15,,128.152,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,128.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.86,38,,22.288,percent of total billed charges,38% of total billed charges,23.43,31.95,,160.44,percent of total billed charges,31.95% of total billed charges,0.08,62.32,
acyclovir 50 mg/mL Sol 10 mL [FMC],2584517,CDM,250,RC,J0133,HCPCS,OUTPATIENT,10,ML,52,31.2,,44.2,85,,35.36,Percent of total billed charges,85% of total billed charges,0.08,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,18.28,35.15,,52.864,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.76,38,,15.808,percent of total billed charges,38% of total billed charges,16.61,31.95,,48.056,percent of total billed charges,31.95% of total billed charges,0.08,44.2,
raltegravir 400 mg Tab,2584522,CDM,250,RC,,,OUTPATIENT,1,EA,89.5,53.7,,76.08,85,,60.864,Percent of total billed charges,85% of total billed charges,44.75,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.75,50,,13.6,percent of total billed charges,50% of total billed charges,28.6,31.95,,646.76,percent of total billed charges,31.95% of total billed charges,28.6,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.01,38,,27.208,percent of total billed charges,38% of total billed charges,35.8,40,,587.88,percent of total billed charges,40% of total billed charges,28.6,76.08,
linaclotide 145 mcg Cap [FMC],2584530,CDM,250,RC,,,OUTPATIENT,1,EA,38.15,22.89,,32.43,85,,25.944,Percent of total billed charges,85% of total billed charges,19.08,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.08,50,,6.8,percent of total billed charges,50% of total billed charges,12.19,31.95,,329.008,percent of total billed charges,31.95% of total billed charges,12.19,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.5,38,,11.6,percent of total billed charges,38% of total billed charges,15.26,40,,299.056,percent of total billed charges,40% of total billed charges,12.19,32.43,
bupivacaine liposome 1.3% (13.3 mg/mL) Sus [FMC],2584548,CDM,250,RC,C9290,HCPCS,OUTPATIENT,20,ML,1424.14,854.484,,1210.52,85,,968.416,Percent of total billed charges,85% of total billed charges,2.04,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.04,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,500.59,35.15,,95.848,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,541.17,38,,432.936,percent of total billed charges,38% of total billed charges,455.01,31.95,,120,percent of total billed charges,31.95% of total billed charges,2.04,1210.52,
dalbavancin 500 mg REC [FMC],2584555,CDM,250,RC,J0875,HCPCS,OUTPATIENT,1,EA,6540.3,3924.18,,5559.26,85,,4447.408,Percent of total billed charges,85% of total billed charges,22.85,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.85,136.6,,17.04,fee schedule,136.60% of BCBS custom fee schedule,2298.92,35.15,,21.088,fee schedule,35.15% of LA custom fee schedule,2089.63,31.95,,76.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,2485.31,38,,1988.248,percent of total billed charges,38% of total billed charges,2089.63,31.95,,19.168,Fee Schedule,31.95% of LA custom fee schedule,22.85,5559.26,
ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus [FMC],2584563,CDM,250,RC,,,OUTPATIENT,7.5,EA,874.31,524.586,,743.16,85,,594.528,Percent of total billed charges,85% of total billed charges,437.16,50,,17.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,437.16,50,,18,percent of total billed charges,50% of total billed charges,279.34,31.95,,21.088,percent of total billed charges,31.95% of total billed charges,279.34,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,332.24,38,,265.792,percent of total billed charges,38% of total billed charges,349.72,40,,19.168,percent of total billed charges,40% of total billed charges,279.34,743.16,
ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus [FMC],2584563,CDM,250,RC,,,OUTPATIENT,7.5,EA,910.75,546.45,,774.14,85,,619.312,Percent of total billed charges,85% of total billed charges,455.38,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,455.38,50,,17.04,percent of total billed charges,50% of total billed charges,290.98,31.95,,21.088,percent of total billed charges,31.95% of total billed charges,290.98,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,346.09,38,,276.872,percent of total billed charges,38% of total billed charges,364.3,40,,19.168,percent of total billed charges,40% of total billed charges,290.98,774.14,
ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus [FMC],2584563,CDM,250,RC,,,OUTPATIENT,7.5,EA,971.46,582.876,,825.74,85,,660.592,Percent of total billed charges,85% of total billed charges,485.73,50,,17.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,485.73,50,,24.4,percent of total billed charges,50% of total billed charges,310.38,31.95,,21.088,percent of total billed charges,31.95% of total billed charges,310.38,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,369.15,38,,295.32,percent of total billed charges,38% of total billed charges,388.58,40,,19.168,percent of total billed charges,40% of total billed charges,310.38,825.74,
morphine 2 mg/mL preservative-free Inj Soln 1 mL [FMC],2584589,CDM,250,RC,J2270,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,6.49,136.6,,24.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.49,136.6,,30.8,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,153.36,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,192,percent of total billed charges,31.95% of total billed charges,4.47,11.9,
morphine 2 mg/mL preservative-free Inj Soln 1 mL [FMC],2584589,CDM,250,RC,J2270,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,6.49,136.6,,30.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6.49,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,153.36,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,192,percent of total billed charges,31.95% of total billed charges,4.47,11.9,
clindamycin 900 mg-5%/50 mL Sol [FMC],2584605,CDM,250,RC,J0736,HCPCS,OUTPATIENT,50,ML,83.11,49.866,,70.64,85,,56.512,Percent of total billed charges,85% of total billed charges,3.03,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.03,136.6,,45.6,fee schedule,136.60% of BCBS custom fee schedule,29.21,35.15,,19.168,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.58,38,,25.264,percent of total billed charges,38% of total billed charges,26.55,31.95,,24,percent of total billed charges,31.95% of total billed charges,3.03,70.64,
clindamycin 900 mg-5%/50 mL Sol [FMC],2584605,CDM,250,RC,J0736,HCPCS,OUTPATIENT,50,ML,50.9,30.54,,43.27,85,,34.616,Percent of total billed charges,85% of total billed charges,3.03,136.6,,45.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.03,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,17.89,35.15,,774.72,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,774.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.34,38,,15.472,percent of total billed charges,38% of total billed charges,16.26,31.95,,969.92,percent of total billed charges,31.95% of total billed charges,3.03,43.27,
clindamycin 900 mg-5%/50 mL Sol [FMC] -  - Inpatient - FMC HOSP - Active - 00338-3814-24,2584605,CDM,250,RC,J0736,HCPCS,OUTPATIENT,50,ML,58.9,35.34,,50.07,85,,40.056,Percent of total billed charges,85% of total billed charges,3.03,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.03,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,20.7,35.15,,89.968,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,89.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.38,38,,17.904,percent of total billed charges,38% of total billed charges,18.82,31.95,,112.64,percent of total billed charges,31.95% of total billed charges,3.03,50.07,
clindamycin 900 mg-5%/50 mL Sol [FMC],2584605,CDM,250,RC,J0736,HCPCS,OUTPATIENT,50,ML,50.9,30.54,,43.27,85,,34.616,Percent of total billed charges,85% of total billed charges,3.03,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.03,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,17.89,35.15,,89.968,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,89.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.34,38,,15.472,percent of total billed charges,38% of total billed charges,16.26,31.95,,112.64,percent of total billed charges,31.95% of total billed charges,3.03,43.27,
potassium chloride 20 mEq REC [FMC],2584613,CDM,250,RC,,,OUTPATIENT,1,EA,34.9,20.94,,29.67,85,,23.736,Percent of total billed charges,85% of total billed charges,17.45,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.45,50,,13.2,percent of total billed charges,50% of total billed charges,11.15,31.95,,137.792,percent of total billed charges,31.95% of total billed charges,11.15,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.26,38,,10.608,percent of total billed charges,38% of total billed charges,13.96,40,,125.248,percent of total billed charges,40% of total billed charges,11.15,29.67,
potassium chloride 20 mEq REC [FMC],2584613,CDM,250,RC,,,OUTPATIENT,1,EA,34.9,20.94,,29.67,85,,23.736,Percent of total billed charges,85% of total billed charges,17.45,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.45,50,,14,percent of total billed charges,50% of total billed charges,11.15,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,11.15,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.26,38,,10.608,percent of total billed charges,38% of total billed charges,13.96,40,,222.08,percent of total billed charges,40% of total billed charges,11.15,29.67,
menthol 4 % Gel [FMC],2584621,CDM,250,RC,,,OUTPATIENT,1,EA,80.24,48.144,,68.2,85,,54.56,Percent of total billed charges,85% of total billed charges,40.12,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.12,50,,13.2,percent of total billed charges,50% of total billed charges,25.64,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,25.64,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.49,38,,24.392,percent of total billed charges,38% of total billed charges,32.1,40,,222.08,percent of total billed charges,40% of total billed charges,25.64,68.2,
scopolamine 1 mg Transderm ER Film [FMC],2584639,CDM,250,RC,,,OUTPATIENT,1,EA,65.29,39.174,,55.5,85,,44.4,Percent of total billed charges,85% of total billed charges,32.65,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.65,50,,14,percent of total billed charges,50% of total billed charges,20.86,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,20.86,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.81,38,,19.848,percent of total billed charges,38% of total billed charges,26.12,40,,222.08,percent of total billed charges,40% of total billed charges,20.86,55.5,
scopolamine 1 mg Transderm ER Film [FMC],2584639,CDM,250,RC,,,OUTPATIENT,1,EA,65.65,39.39,,55.8,85,,44.64,Percent of total billed charges,85% of total billed charges,32.83,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.83,50,,13.2,percent of total billed charges,50% of total billed charges,20.98,31.95,,960.032,percent of total billed charges,31.95% of total billed charges,20.98,31.95,,960.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.95,38,,19.96,percent of total billed charges,38% of total billed charges,26.26,40,,1201.92,percent of total billed charges,40% of total billed charges,20.98,55.8,
scopolamine 1 mg Transderm ER Film [FMC],2584639,CDM,250,RC,,,OUTPATIENT,1,EA,62.6,37.56,,53.21,85,,42.568,Percent of total billed charges,85% of total billed charges,31.3,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.3,50,,13.2,percent of total billed charges,50% of total billed charges,20,31.95,,960.032,percent of total billed charges,31.95% of total billed charges,20,31.95,,960.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.79,38,,19.032,percent of total billed charges,38% of total billed charges,25.04,40,,1201.92,percent of total billed charges,40% of total billed charges,20,53.21,
scopolamine 1 mg Transderm ER Film [FMC],2584639,CDM,250,RC,,,OUTPATIENT,1,EA,65.65,39.39,,55.8,85,,44.64,Percent of total billed charges,85% of total billed charges,32.83,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.83,50,,17.2,percent of total billed charges,50% of total billed charges,20.98,31.95,,960.032,percent of total billed charges,31.95% of total billed charges,20.98,31.95,,960.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.95,38,,19.96,percent of total billed charges,38% of total billed charges,26.26,40,,1201.92,percent of total billed charges,40% of total billed charges,20.98,55.8,
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Soln UD oral syringe [FMC],2584654,CDM,250,RC,,,OUTPATIENT,15,ML,17.3,10.38,,14.71,85,,11.768,Percent of total billed charges,85% of total billed charges,8.65,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.65,50,,17.2,percent of total billed charges,50% of total billed charges,5.53,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,5.53,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.57,38,,5.256,percent of total billed charges,38% of total billed charges,6.92,40,,672,percent of total billed charges,40% of total billed charges,5.53,14.71,
acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Soln UD oral syringe [FMC],2584654,CDM,250,RC,,,OUTPATIENT,15,ML,24.12,14.472,,20.5,85,,16.4,Percent of total billed charges,85% of total billed charges,12.06,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.06,50,,17.2,percent of total billed charges,50% of total billed charges,7.71,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,7.71,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.17,38,,7.336,percent of total billed charges,38% of total billed charges,9.65,40,,672,percent of total billed charges,40% of total billed charges,7.71,20.5,
HYDROmorphone 0.5 mg/0.5 mL Sol [FMC],2584738,CDM,250,RC,J1171,HCPCS,OUTPATIENT,0.5,ML,14.04,8.424,,11.93,85,,9.544,Percent of total billed charges,85% of total billed charges,7.02,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.02,50,,17.6,percent of total billed charges,50% of total billed charges,4.94,35.15,,536.76,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.34,38,,4.272,percent of total billed charges,38% of total billed charges,4.49,31.95,,672,percent of total billed charges,31.95% of total billed charges,4.49,11.93,
HYDROmorphone 0.5 mg/0.5 mL Sol [FMC],2584738,CDM,250,RC,J1171,HCPCS,OUTPATIENT,0.5,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,17.2,percent of total billed charges,50% of total billed charges,4.92,35.15,,177.384,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,222.08,percent of total billed charges,31.95% of total billed charges,4.47,11.9,
Amino Acids 5% with 20% Dextrose and Electrolytes (Clinimix E) 1000 ml [FMC],2584761,CDM,250,RC,,,OUTPATIENT,1000,ML,176.61,105.966,,150.12,85,,120.096,Percent of total billed charges,85% of total billed charges,88.31,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,88.31,50,,12.8,percent of total billed charges,50% of total billed charges,56.43,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,56.43,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,67.11,38,,53.688,percent of total billed charges,38% of total billed charges,70.64,40,,104.64,percent of total billed charges,40% of total billed charges,56.43,150.12,
indigo carmine 8 mg/mL Sol [FMC],2584787,CDM,250,RC,,,OUTPATIENT,1,ML,135.98,81.588,,115.58,85,,92.464,Percent of total billed charges,85% of total billed charges,67.99,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67.99,50,,14,percent of total billed charges,50% of total billed charges,43.45,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,43.45,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,51.67,38,,41.336,percent of total billed charges,38% of total billed charges,54.39,40,,104.64,percent of total billed charges,40% of total billed charges,43.45,115.58,
vancomycin 1 Gm TOP POWDER [FMC],2584829,CDM,250,RC,,,OUTPATIENT,1,EA,113.75,68.25,,96.69,85,,77.352,Percent of total billed charges,85% of total billed charges,56.88,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.88,50,,13.2,percent of total billed charges,50% of total billed charges,36.34,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,36.34,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.23,38,,34.584,percent of total billed charges,38% of total billed charges,45.5,40,,104.64,percent of total billed charges,40% of total billed charges,36.34,96.69,
sodium hyaluronate 10 mg/mL Sol [FMC],2584837,CDM,250,RC,J7321,HCPCS,OUTPATIENT,2,ML,741,444.6,,629.85,85,,503.88,Percent of total billed charges,85% of total billed charges,113.86,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,113.86,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,260.46,35.15,,341.224,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,341.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,281.58,38,,225.264,percent of total billed charges,38% of total billed charges,236.75,31.95,,427.2,percent of total billed charges,31.95% of total billed charges,8.15,629.85,
sodium hypochlorite topical 0.125% Sol [FMC],2584852,CDM,250,RC,,,OUTPATIENT,473,EA,45.04,27.024,,38.28,85,,30.624,Percent of total billed charges,85% of total billed charges,22.52,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.52,50,,4,percent of total billed charges,50% of total billed charges,14.39,31.95,,341.224,percent of total billed charges,31.95% of total billed charges,14.39,31.95,,341.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.12,38,,13.696,percent of total billed charges,38% of total billed charges,18.02,40,,427.2,percent of total billed charges,40% of total billed charges,14.39,38.28,
sodium hypochlorite topical 0.125% Sol [FMC],2584852,CDM,250,RC,,,OUTPATIENT,473,EA,45.33,27.198,,38.53,85,,30.824,Percent of total billed charges,85% of total billed charges,22.67,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.67,50,,9.6,percent of total billed charges,50% of total billed charges,14.48,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,14.48,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.23,38,,13.784,percent of total billed charges,38% of total billed charges,18.13,40,,222.08,percent of total billed charges,40% of total billed charges,14.48,38.53,
phenol topical 1.4% Spr [FMC],2584860,CDM,250,RC,,,OUTPATIENT,177,ML,8.12,4.872,,6.9,85,,5.52,Percent of total billed charges,85% of total billed charges,4.06,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.06,50,,9.6,percent of total billed charges,50% of total billed charges,2.59,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,2.59,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.09,38,,2.472,percent of total billed charges,38% of total billed charges,3.25,40,,222.08,percent of total billed charges,40% of total billed charges,2.59,6.9,
phenol topical 1.4% Spr,2584860,CDM,250,RC,,,OUTPATIENT,177,ML,12.84,7.704,,10.91,85,,8.728,Percent of total billed charges,85% of total billed charges,6.42,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.42,50,,10.8,percent of total billed charges,50% of total billed charges,4.1,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,4.1,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.88,38,,3.904,percent of total billed charges,38% of total billed charges,5.14,40,,222.08,percent of total billed charges,40% of total billed charges,4.1,10.91,
Pharmacy Compound 15 mL Soln,2584878,CDM,250,RC,,,OUTPATIENT,90,ML,149.18,89.508,,126.8,85,,101.44,Percent of total billed charges,85% of total billed charges,74.59,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,74.59,50,,11.2,percent of total billed charges,50% of total billed charges,47.66,31.95,,923.992,percent of total billed charges,31.95% of total billed charges,47.66,31.95,,923.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,56.69,38,,45.352,percent of total billed charges,38% of total billed charges,59.67,40,,1156.8,percent of total billed charges,40% of total billed charges,47.66,126.8,
gentamicin Top 0.1% Oint [FMC],2584886,CDM,250,RC,,,OUTPATIENT,15,EA,11.7,7.02,,9.95,85,,7.96,Percent of total billed charges,85% of total billed charges,5.85,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.85,50,,10.8,percent of total billed charges,50% of total billed charges,3.74,31.95,,158.472,percent of total billed charges,31.95% of total billed charges,3.74,31.95,,158.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.45,38,,3.56,percent of total billed charges,38% of total billed charges,4.68,40,,198.4,percent of total billed charges,40% of total billed charges,3.74,9.95,
gentamicin Top 0.1% Oint [FMC],2584886,CDM,250,RC,,,OUTPATIENT,15,EA,160.49,96.294,,136.42,85,,109.136,Percent of total billed charges,85% of total billed charges,80.25,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,80.25,50,,11.6,percent of total billed charges,50% of total billed charges,51.28,31.95,,314.392,percent of total billed charges,31.95% of total billed charges,51.28,31.95,,314.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.99,38,,48.792,percent of total billed charges,38% of total billed charges,64.2,40,,393.6,percent of total billed charges,40% of total billed charges,51.28,136.42,
endoscopic tattoo 5 mL Syringe [FMC],2584894,CDM,250,RC,,,OUTPATIENT,1,ML,113.75,68.25,,96.69,85,,77.352,Percent of total billed charges,85% of total billed charges,56.88,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.88,50,,11.6,percent of total billed charges,50% of total billed charges,36.34,31.95,,314.392,percent of total billed charges,31.95% of total billed charges,36.34,31.95,,314.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.23,38,,34.584,percent of total billed charges,38% of total billed charges,45.5,40,,393.6,percent of total billed charges,40% of total billed charges,36.34,96.69,
acetaminophen 160 mg/5 mL Susp UD [FMC],2584928,CDM,250,RC,,,OUTPATIENT,5,ML,3.24,1.944,,2.75,85,,2.2,Percent of total billed charges,85% of total billed charges,1.62,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.62,50,,11.2,percent of total billed charges,50% of total billed charges,1.04,31.95,,314.392,percent of total billed charges,31.95% of total billed charges,1.04,31.95,,314.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.23,38,,0.984,percent of total billed charges,38% of total billed charges,1.3,40,,393.6,percent of total billed charges,40% of total billed charges,1.04,2.75,
acetaminophen 160 mg/5 mL Susp UD [FMC],2584928,CDM,250,RC,,,OUTPATIENT,5,ML,4.61,2.766,,3.92,85,,3.136,Percent of total billed charges,85% of total billed charges,2.31,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.31,50,,11.2,percent of total billed charges,50% of total billed charges,1.47,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,1.47,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.75,38,,1.4,percent of total billed charges,38% of total billed charges,1.84,40,,222.08,percent of total billed charges,40% of total billed charges,1.47,3.92,
acetaminophen 160 mg/5 mL Sus,2584928,CDM,250,RC,,,OUTPATIENT,5,ML,3.28,1.968,,2.79,85,,2.232,Percent of total billed charges,85% of total billed charges,1.64,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.64,50,,1.6,percent of total billed charges,50% of total billed charges,1.05,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,1.05,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.25,38,,1,percent of total billed charges,38% of total billed charges,1.31,40,,222.08,percent of total billed charges,40% of total billed charges,1.05,2.79,
onabotulinumtoxinA 100 units REC [FMC],2584936,CDM,250,RC,J0585,HCPCS,OUTPATIENT,1,EA,2343.9,1406.34,,1992.32,85,,1593.856,Percent of total billed charges,85% of total billed charges,8.73,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.73,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,823.88,35.15,,177.384,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,890.68,38,,712.544,percent of total billed charges,38% of total billed charges,748.88,31.95,,222.08,percent of total billed charges,31.95% of total billed charges,8.15,1992.32,
amiodarone 50 mg/mL IV 3ml Sol [FMC],2584944,CDM,250,RC,J0282,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,177.384,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,222.08,percent of total billed charges,31.95% of total billed charges,0.71,10.2,
amiodarone 50 mg/mL IV 3ml Sol [FMC],2584944,CDM,250,RC,J0282,HCPCS,OUTPATIENT,3,ML,14.16,8.496,,12.04,85,,9.632,Percent of total billed charges,85% of total billed charges,0.71,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,48,fee schedule,136.60% of BCBS custom fee schedule,4.98,35.15,,177.384,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.38,38,,4.304,percent of total billed charges,38% of total billed charges,4.52,31.95,,222.08,percent of total billed charges,31.95% of total billed charges,0.71,12.04,
amiodarone 50 mg/mL IV 3ml Sol [FMC],2584944,CDM,250,RC,J0282,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,48,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,177.384,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,222.08,percent of total billed charges,31.95% of total billed charges,0.71,10.2,
amiodarone 50 mg/mL IV 3ml Sol [FMC],2584944,CDM,250,RC,J0282,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.71,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,313.624,percent of total billed charges,35.15% of total billed charges,8.15,31.95,,313.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,392.64,percent of total billed charges,31.95% of total billed charges,0.71,10.2,
"rabies immune globulin, human 300 intl units/mL Sol 5ml [FMC]",2584951,CDM,250,RC,,,OUTPATIENT,5,ML,13269.59,7961.754,,11279.15,85,,9023.32,Percent of total billed charges,85% of total billed charges,6634.8,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6634.8,50,,3.08,percent of total billed charges,50% of total billed charges,4239.63,31.95,,313.624,percent of total billed charges,31.95% of total billed charges,4239.63,31.95,,313.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5042.44,38,,4033.952,percent of total billed charges,38% of total billed charges,5307.84,40,,392.64,percent of total billed charges,40% of total billed charges,4239.63,11279.15,
metaxalone 800 mg Tab [FMC],2584969,CDM,250,RC,,,OUTPATIENT,1,EA,19.47,11.682,,16.55,85,,13.24,Percent of total billed charges,85% of total billed charges,9.74,50,,3.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.74,50,,108,percent of total billed charges,50% of total billed charges,6.22,31.95,,313.624,percent of total billed charges,31.95% of total billed charges,6.22,31.95,,313.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.4,38,,5.92,percent of total billed charges,38% of total billed charges,7.79,40,,392.64,percent of total billed charges,40% of total billed charges,6.22,16.55,
metaxalone 800 mg Tab [FMC],2584969,CDM,250,RC,,,OUTPATIENT,1,EA,19.84,11.904,,16.86,85,,13.488,Percent of total billed charges,85% of total billed charges,9.92,50,,108,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.92,50,,2.8,percent of total billed charges,50% of total billed charges,6.34,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,6.34,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.54,38,,6.032,percent of total billed charges,38% of total billed charges,7.94,40,,1477.76,percent of total billed charges,40% of total billed charges,6.34,16.86,
metaxalone 800 mg Tab [FMC],2584969,CDM,250,RC,,,OUTPATIENT,1,EA,48.39,29.034,,41.13,85,,32.904,Percent of total billed charges,85% of total billed charges,24.2,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.2,50,,6.4,percent of total billed charges,50% of total billed charges,15.46,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,15.46,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.39,38,,14.712,percent of total billed charges,38% of total billed charges,19.36,40,,1477.76,percent of total billed charges,40% of total billed charges,15.46,41.13,
triamcinolone topical 0.1% Cream 454 gm [FMC],2584977,CDM,250,RC,,,OUTPATIENT,454,EA,76.73,46.038,,65.22,85,,52.176,Percent of total billed charges,85% of total billed charges,38.37,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38.37,50,,6,percent of total billed charges,50% of total billed charges,24.52,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,24.52,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.16,38,,23.328,percent of total billed charges,38% of total billed charges,30.69,40,,1477.76,percent of total billed charges,40% of total billed charges,24.52,65.22,
triamcinolone topical 0.1% Cream 454 gm [FMC],2584977,CDM,250,RC,,,OUTPATIENT,454,EA,101.07,60.642,,85.91,85,,68.728,Percent of total billed charges,85% of total billed charges,50.54,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50.54,50,,6.4,percent of total billed charges,50% of total billed charges,32.29,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,32.29,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.41,38,,30.728,percent of total billed charges,38% of total billed charges,40.43,40,,222.08,percent of total billed charges,40% of total billed charges,32.29,85.91,
diltiazem 5 mg/ml  IV 5mL Sol [FMC],2584985,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,6.4,percent of total billed charges,50% of total billed charges,3.83,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,222.08,percent of total billed charges,40% of total billed charges,3.83,10.2,
diltiazem 5 mg/ml  IV 5mL Sol [FMC],2584985,CDM,250,RC,,,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,6,percent of total billed charges,50% of total billed charges,3.83,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,222.08,percent of total billed charges,40% of total billed charges,3.83,10.2,
diltiazem 5 mg/ml  IV 5mL Sol [FMC],2584985,CDM,250,RC,,,OUTPATIENT,5,ML,13.34,8.004,,11.34,85,,9.072,Percent of total billed charges,85% of total billed charges,6.67,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.67,50,,29.6,percent of total billed charges,50% of total billed charges,4.26,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,4.26,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.07,38,,4.056,percent of total billed charges,38% of total billed charges,5.34,40,,107.52,percent of total billed charges,40% of total billed charges,4.26,11.34,
hydrocortisone Top 2.5% Crm [FMC],2584993,CDM,250,RC,,,OUTPATIENT,28,EA,35.1,21.06,,29.84,85,,23.872,Percent of total billed charges,85% of total billed charges,17.55,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.55,50,,25.144,percent of total billed charges,50% of total billed charges,11.21,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,11.21,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.34,38,,10.672,percent of total billed charges,38% of total billed charges,14.04,40,,107.52,percent of total billed charges,40% of total billed charges,11.21,29.84,
hydrocortisone Top 2.5% Crm [FMC],2584993,CDM,250,RC,,,OUTPATIENT,28,EA,33.37,20.022,,28.36,85,,22.688,Percent of total billed charges,85% of total billed charges,16.69,50,,25.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.69,50,,16,percent of total billed charges,50% of total billed charges,10.66,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,10.66,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.68,38,,10.144,percent of total billed charges,38% of total billed charges,13.35,40,,107.52,percent of total billed charges,40% of total billed charges,10.66,28.36,
triamcinolone Top 0.1% Oint [FMC],2585008,CDM,250,RC,,,OUTPATIENT,15,EA,18.82,11.292,,16,85,,12.8,Percent of total billed charges,85% of total billed charges,9.41,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.41,50,,16,percent of total billed charges,50% of total billed charges,6.01,31.95,,110.672,percent of total billed charges,31.95% of total billed charges,6.01,31.95,,110.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.15,38,,5.72,percent of total billed charges,38% of total billed charges,7.53,40,,138.56,percent of total billed charges,40% of total billed charges,6.01,16,
triamcinolone Top 0.1% Oint [FMC],2585008,CDM,250,RC,,,OUTPATIENT,15,EA,18.14,10.884,,15.42,85,,12.336,Percent of total billed charges,85% of total billed charges,9.07,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.07,50,,15.784,percent of total billed charges,50% of total billed charges,5.8,31.95,,110.672,percent of total billed charges,31.95% of total billed charges,5.8,31.95,,110.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.89,38,,5.512,percent of total billed charges,38% of total billed charges,7.26,40,,138.56,percent of total billed charges,40% of total billed charges,5.8,15.42,
triamcinolone Top 0.1% Oint [FMC],2585008,CDM,250,RC,,,OUTPATIENT,15,EA,18.33,10.998,,15.58,85,,12.464,Percent of total billed charges,85% of total billed charges,9.17,50,,15.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.17,50,,13.2,percent of total billed charges,50% of total billed charges,5.86,31.95,,110.672,percent of total billed charges,31.95% of total billed charges,5.86,31.95,,110.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.97,38,,5.576,percent of total billed charges,38% of total billed charges,7.33,40,,138.56,percent of total billed charges,40% of total billed charges,5.86,15.58,
chlorhexidine oral rinse Sol 473 ml [FMC],2585024,CDM,250,RC,,,OUTPATIENT,473,ML,34.13,20.478,,29.01,85,,23.208,Percent of total billed charges,85% of total billed charges,17.07,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.07,50,,8.8,percent of total billed charges,50% of total billed charges,10.9,31.95,,1280.304,percent of total billed charges,31.95% of total billed charges,10.9,31.95,,1280.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.97,38,,10.376,percent of total billed charges,38% of total billed charges,13.65,40,,1602.88,percent of total billed charges,40% of total billed charges,10.9,29.01,
lidocaine topical 2% Gel URJT [FMC],2585032,CDM,250,RC,,,OUTPATIENT,10,ML,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,8.8,percent of total billed charges,50% of total billed charges,7.99,31.95,,1280.304,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,1280.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,7.6,percent of total billed charges,38% of total billed charges,10,40,,1602.88,percent of total billed charges,40% of total billed charges,7.99,21.25,
lidocaine topical 2% Gel URJT [FMC],2585032,CDM,250,RC,,,OUTPATIENT,10,ML,38.68,23.208,,32.88,85,,26.304,Percent of total billed charges,85% of total billed charges,19.34,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.34,50,,8.4,percent of total billed charges,50% of total billed charges,12.36,31.95,,1280.304,percent of total billed charges,31.95% of total billed charges,12.36,31.95,,1280.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.7,38,,11.76,percent of total billed charges,38% of total billed charges,15.47,40,,1602.88,percent of total billed charges,40% of total billed charges,12.36,32.88,
lidocaine topical 2% Gel URJT [FMC],2585032,CDM,250,RC,,,OUTPATIENT,10,ML,22.51,13.506,,19.13,85,,15.304,Percent of total billed charges,85% of total billed charges,11.26,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.26,50,,8.8,percent of total billed charges,50% of total billed charges,7.19,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,7.19,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.55,38,,6.84,percent of total billed charges,38% of total billed charges,9,40,,222.08,percent of total billed charges,40% of total billed charges,7.19,19.13,
acetaminophen 10 mg/mL Sol [FMC],2585040,CDM,250,RC,J0131,HCPCS,OUTPATIENT,100,ML,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,27.42,35.15,,177.384,percent of total billed charges,35.15% of total billed charges,79.88,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,23.712,percent of total billed charges,38% of total billed charges,24.92,31.95,,222.08,percent of total billed charges,31.95% of total billed charges,0.11,79.88,
acetaminophen 10 mg/mL Sol [FMC],2585040,CDM,250,RC,J0131,HCPCS,OUTPATIENT,100,ML,138.56,83.136,,117.78,85,,94.224,Percent of total billed charges,85% of total billed charges,0.11,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,48.7,35.15,,177.384,percent of total billed charges,35.15% of total billed charges,79.88,31.95,,177.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,52.65,38,,42.12,percent of total billed charges,38% of total billed charges,44.27,31.95,,222.08,percent of total billed charges,31.95% of total billed charges,0.11,117.78,
acetaminophen 10 mg/mL Sol [FMC],2585040,CDM,250,RC,J0131,HCPCS,OUTPATIENT,100,ML,144.33,86.598,,122.68,85,,98.144,Percent of total billed charges,85% of total billed charges,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,50.73,35.15,,85.624,percent of total billed charges,35.15% of total billed charges,81.15,31.95,,85.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.85,38,,43.88,percent of total billed charges,38% of total billed charges,46.11,31.95,,107.2,percent of total billed charges,31.95% of total billed charges,0.11,122.68,
acetaminophen 10 mg/mL Sol [FMC],2585040,CDM,250,RC,J0131,HCPCS,OUTPATIENT,100,ML,146.25,87.75,,124.31,85,,99.448,Percent of total billed charges,85% of total billed charges,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,51.41,35.15,,86.136,percent of total billed charges,35.15% of total billed charges,81.15,31.95,,86.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.58,38,,44.464,percent of total billed charges,38% of total billed charges,46.73,31.95,,107.84,percent of total billed charges,31.95% of total billed charges,0.11,124.31,
acetaminophen 10 mg/mL Sol [FMC],2585040,CDM,250,RC,J0131,HCPCS,OUTPATIENT,100,ML,144.33,86.598,,122.68,85,,98.144,Percent of total billed charges,85% of total billed charges,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,50.73,35.15,,85.624,percent of total billed charges,35.15% of total billed charges,81.15,31.95,,85.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.85,38,,43.88,percent of total billed charges,38% of total billed charges,46.11,31.95,,107.2,percent of total billed charges,31.95% of total billed charges,0.11,122.68,
acetaminophen 10 mg/mL Sol [FMC],2585040,CDM,250,RC,J0131,HCPCS,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,0.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.11,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,12.65,35.15,,165.632,percent of total billed charges,35.15% of total billed charges,82.43,31.95,,165.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,11.5,31.95,,207.36,percent of total billed charges,31.95% of total billed charges,0.11,82.43,
ceFAZolin 2 g/50 mL IVPB Premix Soln [FMC],2585057,CDM,250,RC,J0690,HCPCS,OUTPATIENT,1,ML,57.56,34.536,,48.93,85,,39.144,Percent of total billed charges,85% of total billed charges,1.09,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.09,136.6,,10.24,fee schedule,136.60% of BCBS custom fee schedule,20.23,35.15,,166.144,fee schedule,35.15% of LA custom fee schedule,18.39,31.95,,166.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,21.87,38,,17.496,percent of total billed charges,38% of total billed charges,18.39,31.95,,208,Fee Schedule,31.95% of LA custom fee schedule,1.09,48.93,
naltrexone 50 mg Tab UD [FMC],2585065,CDM,250,RC,,,OUTPATIENT,1,EA,14.01,8.406,,11.91,85,,9.528,Percent of total billed charges,85% of total billed charges,7.01,50,,10.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.01,50,,14,percent of total billed charges,50% of total billed charges,4.48,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,4.48,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,5.6,40,,188.8,percent of total billed charges,40% of total billed charges,4.48,11.91,
sodium hyaluronate 10 mg/mL 2ml Syringe Sol [FMC],2585099,CDM,250,RC,J7323,HCPCS,OUTPATIENT,2,ML,1325.72,795.432,,1126.86,85,,901.488,Percent of total billed charges,85% of total billed charges,185.02,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,185.02,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,465.99,35.15,,150.808,percent of total billed charges,35.15% of total billed charges,83.07,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,503.77,38,,403.016,percent of total billed charges,38% of total billed charges,423.57,31.95,,188.8,percent of total billed charges,31.95% of total billed charges,83.07,1126.86,
DAPTOmycin 500 mg REC [FMC],2585107,CDM,250,RC,J0878,HCPCS,OUTPATIENT,1,EA,409.5,245.7,,348.08,85,,278.464,Percent of total billed charges,85% of total billed charges,0.05,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,143.94,35.15,,219.816,percent of total billed charges,35.15% of total billed charges,84.03,31.95,,219.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,155.61,38,,124.488,percent of total billed charges,38% of total billed charges,130.84,31.95,,275.2,percent of total billed charges,31.95% of total billed charges,0.05,348.08,
DAPTOmycin 500 mg REC [FMC],2585107,CDM,250,RC,J0878,HCPCS,OUTPATIENT,1,EA,1737.42,1042.452,,1476.81,85,,1181.448,Percent of total billed charges,85% of total billed charges,0.05,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,610.7,35.15,,29.808,percent of total billed charges,35.15% of total billed charges,84.03,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,660.22,38,,528.176,percent of total billed charges,38% of total billed charges,555.11,31.95,,27.096,percent of total billed charges,31.95% of total billed charges,0.05,1476.81,
DAPTOmycin 500 mg REC [FMC],2585107,CDM,250,RC,J0878,HCPCS,OUTPATIENT,1,EA,308.1,184.86,,261.89,85,,209.512,Percent of total billed charges,85% of total billed charges,0.05,136.6,,10.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,108.3,35.15,,836.568,percent of total billed charges,35.15% of total billed charges,85.31,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.08,38,,93.664,percent of total billed charges,38% of total billed charges,98.44,31.95,,760.408,percent of total billed charges,31.95% of total billed charges,0.05,261.89,
DAPTOmycin 500 mg REC [FMC],2585107,CDM,250,RC,J0878,HCPCS,OUTPATIENT,1,EA,234,140.4,,198.9,85,,159.12,Percent of total billed charges,85% of total billed charges,0.05,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,82.25,35.15,,836.568,percent of total billed charges,35.15% of total billed charges,85.31,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.92,38,,71.136,percent of total billed charges,38% of total billed charges,74.76,31.95,,760.408,percent of total billed charges,31.95% of total billed charges,0.05,198.9,
DAPTOmycin 500 mg REC [FMC],2585107,CDM,250,RC,J0878,HCPCS,OUTPATIENT,1,EA,234,140.4,,198.9,85,,159.12,Percent of total billed charges,85% of total billed charges,0.05,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,17.16,fee schedule,136.60% of BCBS custom fee schedule,82.25,35.15,,836.568,percent of total billed charges,35.15% of total billed charges,85.31,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.92,38,,71.136,percent of total billed charges,38% of total billed charges,74.76,31.95,,760.408,percent of total billed charges,31.95% of total billed charges,0.05,198.9,
DAPTOmycin 500 mg REC [FMC],2585107,CDM,250,RC,J0878,HCPCS,OUTPATIENT,1,EA,117,70.2,,99.45,85,,79.56,Percent of total billed charges,85% of total billed charges,0.05,136.6,,17.16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,17.16,fee schedule,136.60% of BCBS custom fee schedule,41.13,35.15,,1295.128,percent of total billed charges,35.15% of total billed charges,85.31,31.95,,1295.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.46,38,,35.568,percent of total billed charges,38% of total billed charges,37.38,31.95,,1621.44,percent of total billed charges,31.95% of total billed charges,0.05,99.45,
aztreonam 1 g REC [FMC],2585115,CDM,250,RC,,,OUTPATIENT,1,EA,128.51,77.106,,109.23,85,,87.384,Percent of total billed charges,85% of total billed charges,64.26,50,,17.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.26,50,,15,percent of total billed charges,50% of total billed charges,41.06,31.95,,380.592,percent of total billed charges,31.95% of total billed charges,41.06,31.95,,380.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.83,38,,39.064,percent of total billed charges,38% of total billed charges,51.4,40,,476.48,percent of total billed charges,40% of total billed charges,41.06,109.23,
aztreonam 1 g REC {FMC},2585115,CDM,250,RC,,,OUTPATIENT,1,EA,128.51,77.106,,109.23,85,,87.384,Percent of total billed charges,85% of total billed charges,64.26,50,,15,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.26,50,,20.28,percent of total billed charges,50% of total billed charges,41.06,31.95,,361.928,percent of total billed charges,31.95% of total billed charges,41.06,31.95,,361.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.83,38,,39.064,percent of total billed charges,38% of total billed charges,51.4,40,,453.12,percent of total billed charges,40% of total billed charges,41.06,109.23,
aztreonam 1 g REC {FMC},2585115,CDM,250,RC,,,OUTPATIENT,1,EA,128.7,77.22,,109.4,85,,87.52,Percent of total billed charges,85% of total billed charges,64.35,50,,20.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.35,50,,4.4,percent of total billed charges,50% of total billed charges,41.12,31.95,,119.232,percent of total billed charges,31.95% of total billed charges,41.12,31.95,,772.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.91,38,,39.128,percent of total billed charges,38% of total billed charges,51.48,40,,108.376,percent of total billed charges,40% of total billed charges,41.12,109.4,
ferric carboxymaltose (as elemental iron) 50 mg/mL Sol [FMC],2585123,CDM,250,RC,J1439,HCPCS,OUTPATIENT,15,ML,5059.24,3035.544,,4300.35,85,,3440.28,Percent of total billed charges,85% of total billed charges,1.68,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.68,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,1778.32,35.15,,119.232,percent of total billed charges,35.15% of total billed charges,85.31,31.95,,772.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1922.51,38,,1538.008,percent of total billed charges,38% of total billed charges,1616.43,31.95,,108.376,percent of total billed charges,31.95% of total billed charges,1.68,4300.35,
thiamine 100 mg Tab [FMC],2585131,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,119.232,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,788.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,108.376,percent of total billed charges,40% of total billed charges,0.96,2.55,
thiamine 100 mg Tab [FMC],2585131,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,13.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,789.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,2.56,percent of total billed charges,40% of total billed charges,0.96,2.55,
thiamine 100 mg Tab [FMC],2585131,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,11.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,49.488,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,800.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,44.984,percent of total billed charges,40% of total billed charges,0.96,2.55,
hyaluronan 30 mg/2 mL Sol [FMC],2585149,CDM,250,RC,J7324,HCPCS,OUTPATIENT,2,ML,1864.2,1118.52,,1584.57,85,,1267.656,Percent of total billed charges,85% of total billed charges,204.75,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.75,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,655.27,35.15,,49.488,percent of total billed charges,35.15% of total billed charges,8.89,31.95,,803.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,708.4,38,,566.72,percent of total billed charges,38% of total billed charges,595.61,31.95,,44.984,percent of total billed charges,31.95% of total billed charges,8.89,1584.57,
hydrocortisone Top 0.5% Oint [FMC],2585156,CDM,250,RC,,,OUTPATIENT,30,EA,13.42,8.052,,11.41,85,,9.128,Percent of total billed charges,85% of total billed charges,6.71,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.71,50,,3.6,percent of total billed charges,50% of total billed charges,4.29,31.95,,49.488,percent of total billed charges,31.95% of total billed charges,4.29,31.95,,815.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.1,38,,4.08,percent of total billed charges,38% of total billed charges,5.37,40,,44.984,percent of total billed charges,40% of total billed charges,4.29,11.41,
nystatin-triamcinolone Top Crm [FMC],2585172,CDM,250,RC,,,OUTPATIENT,15,EA,168.81,101.286,,143.49,85,,114.792,Percent of total billed charges,85% of total billed charges,84.41,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84.41,50,,14.432,percent of total billed charges,50% of total billed charges,53.93,31.95,,119.232,percent of total billed charges,31.95% of total billed charges,53.93,31.95,,830.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.15,38,,51.32,percent of total billed charges,38% of total billed charges,67.52,40,,108.376,percent of total billed charges,40% of total billed charges,53.93,143.49,
nystatin-triamcinolone Top Crm [FMC],2585172,CDM,250,RC,,,OUTPATIENT,15,EA,168.81,101.286,,143.49,85,,114.792,Percent of total billed charges,85% of total billed charges,84.41,50,,14.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84.41,50,,25.2,percent of total billed charges,50% of total billed charges,53.93,31.95,,119.232,percent of total billed charges,31.95% of total billed charges,53.93,31.95,,830.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.15,38,,51.32,percent of total billed charges,38% of total billed charges,67.52,40,,108.376,percent of total billed charges,40% of total billed charges,53.93,143.49,
nystatin-triamcinolone Top Crm [FMC],2585172,CDM,250,RC,,,OUTPATIENT,15,EA,81.71,49.026,,69.45,85,,55.56,Percent of total billed charges,85% of total billed charges,40.86,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40.86,50,,7.6,percent of total billed charges,50% of total billed charges,26.11,31.95,,119.232,percent of total billed charges,31.95% of total billed charges,26.11,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.05,38,,24.84,percent of total billed charges,38% of total billed charges,32.68,40,,108.376,percent of total billed charges,40% of total billed charges,26.11,69.45,
chlorproMAZINE 25 mg/mL Sol [FMC],2585214,CDM,250,RC,J3230,HCPCS,OUTPATIENT,1,ML,112.67,67.602,,95.77,85,,76.616,Percent of total billed charges,85% of total billed charges,47.76,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,47.76,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,39.6,35.15,,49.488,percent of total billed charges,35.15% of total billed charges,86.27,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.81,38,,34.248,percent of total billed charges,38% of total billed charges,36,31.95,,44.984,percent of total billed charges,31.95% of total billed charges,36,95.77,
clotrimazole topical 1% Cre [FMC],2585230,CDM,250,RC,,,OUTPATIENT,30,EA,27.92,16.752,,23.73,85,,18.984,Percent of total billed charges,85% of total billed charges,13.96,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.96,50,,2,percent of total billed charges,50% of total billed charges,8.92,31.95,,49.488,percent of total billed charges,31.95% of total billed charges,8.92,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.61,38,,8.488,percent of total billed charges,38% of total billed charges,11.17,40,,44.984,percent of total billed charges,40% of total billed charges,8.92,23.73,
clotrimazole topical 1% Cre [FMC],2585230,CDM,250,RC,,,OUTPATIENT,30,EA,113.26,67.956,,96.27,85,,77.016,Percent of total billed charges,85% of total billed charges,56.63,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.63,50,,8.8,percent of total billed charges,50% of total billed charges,36.19,31.95,,49.488,percent of total billed charges,31.95% of total billed charges,36.19,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.04,38,,34.432,percent of total billed charges,38% of total billed charges,45.3,40,,44.984,percent of total billed charges,40% of total billed charges,36.19,96.27,
dexamethasone 4 mg Tab UD [FMC],2585255,CDM,250,RC,J8540,HCPCS,OUTPATIENT,1,EA,3.91,2.346,,3.32,85,,2.656,Percent of total billed charges,85% of total billed charges,0.12,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.12,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,1.37,35.15,,146.968,percent of total billed charges,35.15% of total billed charges,86.27,31.95,,146.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.49,38,,1.192,percent of total billed charges,38% of total billed charges,1.25,31.95,,184,percent of total billed charges,31.95% of total billed charges,0.12,86.27,
dexamethasone 4 mg Tab UD [FMC],2585255,CDM,250,RC,J8540,HCPCS,OUTPATIENT,1,EA,3.91,2.346,,3.32,85,,2.656,Percent of total billed charges,85% of total billed charges,0.12,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.12,136.6,,31.6,fee schedule,136.60% of BCBS custom fee schedule,1.37,35.15,,146.968,percent of total billed charges,35.15% of total billed charges,86.27,31.95,,146.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.49,38,,1.192,percent of total billed charges,38% of total billed charges,1.25,31.95,,184,percent of total billed charges,31.95% of total billed charges,0.12,86.27,
dexamethasone 4 mg Tab UD [FMC],2585255,CDM,250,RC,J8540,HCPCS,OUTPATIENT,1,EA,3.91,2.346,,3.32,85,,2.656,Percent of total billed charges,85% of total billed charges,0.12,136.6,,31.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.12,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,1.37,35.15,,167.16,percent of total billed charges,35.15% of total billed charges,86.58,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.49,38,,1.192,percent of total billed charges,38% of total billed charges,1.25,31.95,,209.28,percent of total billed charges,31.95% of total billed charges,0.12,86.58,
amoxicillin-clavulanate 875 mg-125 mg Tab [FMC],2585271,CDM,250,RC,,,OUTPATIENT,1,EA,15.93,9.558,,13.54,85,,10.832,Percent of total billed charges,85% of total billed charges,7.97,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.97,50,,3.32,percent of total billed charges,50% of total billed charges,5.09,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,5.09,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.05,38,,4.84,percent of total billed charges,38% of total billed charges,6.37,40,,209.28,percent of total billed charges,40% of total billed charges,5.09,13.54,
amoxicillin-clavulanate 875 mg-125 mg Tab [FMC],2585271,CDM,250,RC,,,OUTPATIENT,1,EA,16.42,9.852,,13.96,85,,11.168,Percent of total billed charges,85% of total billed charges,8.21,50,,3.32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.21,50,,6,percent of total billed charges,50% of total billed charges,5.25,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5.25,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.24,38,,4.992,percent of total billed charges,38% of total billed charges,6.57,40,,255.04,percent of total billed charges,40% of total billed charges,5.25,13.96,
amoxicillin-clavulanate 875 mg-125 mg Tab [FMC],2585271,CDM,250,RC,,,OUTPATIENT,1,EA,15.93,9.558,,13.54,85,,10.832,Percent of total billed charges,85% of total billed charges,7.97,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.97,50,,4.4,percent of total billed charges,50% of total billed charges,5.09,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5.09,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.05,38,,4.84,percent of total billed charges,38% of total billed charges,6.37,40,,255.04,percent of total billed charges,40% of total billed charges,5.09,13.54,
hydrOXYzine pamoate 25 mg Cap UD [FMC],2585297,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,17.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,255.04,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrOXYzine pamoate 25 mg Cap UD [FMC],2585297,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,6,percent of total billed charges,50% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,255.04,percent of total billed charges,40% of total billed charges,0.96,2.55,
hydrOXYzine pamoate 25 mg Cap UD [FMC],2585297,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,0.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,255.04,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 60 mg ER  UD [FMC],2585313,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,255.04,percent of total billed charges,40% of total billed charges,0.96,2.55,
propranolol 60 mg ER  UD [FMC],2585313,CDM,250,RC,,,OUTPATIENT,1,EA,6.69,4.014,,5.69,85,,4.552,Percent of total billed charges,85% of total billed charges,3.35,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.35,50,,34,percent of total billed charges,50% of total billed charges,2.14,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,2.14,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.54,38,,2.032,percent of total billed charges,38% of total billed charges,2.68,40,,254.72,percent of total billed charges,40% of total billed charges,2.14,5.69,
propranolol 60 mg ER  UD [FMC],2585313,CDM,250,RC,,,OUTPATIENT,1,EA,6.63,3.978,,5.64,85,,4.512,Percent of total billed charges,85% of total billed charges,3.32,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.32,50,,10.4,percent of total billed charges,50% of total billed charges,2.12,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,2.12,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.52,38,,2.016,percent of total billed charges,38% of total billed charges,2.65,40,,254.72,percent of total billed charges,40% of total billed charges,2.12,5.64,
propranolol 60 mg ER  UD [FMC],2585313,CDM,250,RC,,,OUTPATIENT,1,EA,6.69,4.014,,5.69,85,,4.552,Percent of total billed charges,85% of total billed charges,3.35,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.35,50,,15.6,percent of total billed charges,50% of total billed charges,2.14,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,2.14,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.54,38,,2.032,percent of total billed charges,38% of total billed charges,2.68,40,,160,percent of total billed charges,40% of total billed charges,2.14,5.69,
terbutaline 2.5 mg Tab [FMC],2585339,CDM,250,RC,,,OUTPATIENT,1,EA,4.24,2.544,,3.6,85,,2.88,Percent of total billed charges,85% of total billed charges,2.12,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.12,50,,37.2,percent of total billed charges,50% of total billed charges,1.35,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,1.35,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.61,38,,1.288,percent of total billed charges,38% of total billed charges,1.7,40,,254.72,percent of total billed charges,40% of total billed charges,1.35,3.6,
terbutaline 2.5 mg Tab [FMC],2585339,CDM,250,RC,,,OUTPATIENT,1,EA,17.69,10.614,,15.04,85,,12.032,Percent of total billed charges,85% of total billed charges,8.85,50,,37.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.85,50,,3.2,percent of total billed charges,50% of total billed charges,5.65,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5.65,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.72,38,,5.376,percent of total billed charges,38% of total billed charges,7.08,40,,255.04,percent of total billed charges,40% of total billed charges,5.65,15.04,
diazepam 2 mg Tab [FMC],2585354,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,255.04,percent of total billed charges,40% of total billed charges,0.96,2.55,
ticagrelor 90 mg Tab [FMC],2585388,CDM,250,RC,,,OUTPATIENT,1,EA,25.05,15.03,,21.29,85,,17.032,Percent of total billed charges,85% of total billed charges,12.53,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.53,50,,3.2,percent of total billed charges,50% of total billed charges,8,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,8,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.52,38,,7.616,percent of total billed charges,38% of total billed charges,10.02,40,,255.04,percent of total billed charges,40% of total billed charges,8,21.29,
"cholecalciferol 10,000 intl units Cap [FMC]",2585404,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,255.04,percent of total billed charges,40% of total billed charges,0.96,2.55,
ivermectin 3 mg Tab UD [FMC],2585420,CDM,250,RC,,,OUTPATIENT,1,EA,16.15,9.69,,13.73,85,,10.984,Percent of total billed charges,85% of total billed charges,8.08,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.08,50,,15.2,percent of total billed charges,50% of total billed charges,5.16,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,5.16,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.14,38,,4.912,percent of total billed charges,38% of total billed charges,6.46,40,,524.16,percent of total billed charges,40% of total billed charges,5.16,13.73,
ivermectin 3 mg Tab UD [FMC],2585420,CDM,250,RC,,,OUTPATIENT,1,EA,18.14,10.884,,15.42,85,,12.336,Percent of total billed charges,85% of total billed charges,9.07,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.07,50,,15.2,percent of total billed charges,50% of total billed charges,5.8,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,5.8,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.89,38,,5.512,percent of total billed charges,38% of total billed charges,7.26,40,,524.16,percent of total billed charges,40% of total billed charges,5.8,15.42,
remdesivir 100 mg REC Inj [FMC],2585461,CDM,250,RC,J0248,HCPCS,OUTPATIENT,1,EA,2028,1216.8,,1723.8,85,,1379.04,Percent of total billed charges,85% of total billed charges,9.11,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.11,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,712.84,35.15,,101.984,percent of total billed charges,35.15% of total billed charges,86.76,31.95,,101.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,770.64,38,,616.512,percent of total billed charges,38% of total billed charges,647.95,31.95,,127.68,percent of total billed charges,31.95% of total billed charges,9.11,1723.8,
famotidine 20 mg Tab [FMC],2585487,CDM,250,RC,,,OUTPATIENT,1,EA,44.3,26.58,,37.66,85,,30.128,Percent of total billed charges,85% of total billed charges,22.15,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.15,50,,20.4,percent of total billed charges,50% of total billed charges,14.15,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,14.15,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.83,38,,13.464,percent of total billed charges,38% of total billed charges,17.72,40,,255.04,percent of total billed charges,40% of total billed charges,14.15,37.66,
famotidine 20 mg Tab [FMC],2585487,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,20.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,8.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,209.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
famotidine 20 mg Tab [FMC],2585487,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,524.16,percent of total billed charges,40% of total billed charges,0.96,2.55,
famotidine 20 mg Tab [FMC],2585487,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,49.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,524.16,percent of total billed charges,40% of total billed charges,0.96,2.55,
ferumoxytol 30 mg/mL Sol [FMC],2585503,CDM,250,RC,Q0138,HCPCS,OUTPATIENT,17,ML,4178.53,2507.118,,3551.75,85,,2841.4,Percent of total billed charges,85% of total billed charges,0.75,136.6,,49.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,1468.75,35.15,,203.712,percent of total billed charges,35.15% of total billed charges,86.76,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1587.84,38,,1270.272,percent of total billed charges,38% of total billed charges,1335.04,31.95,,255.04,percent of total billed charges,31.95% of total billed charges,0.75,3551.75,
Tobramycin - TOP Powder 5gm [FMC],2585545,CDM,250,RC,,,OUTPATIENT,1,EA,193.05,115.83,,164.09,85,,131.272,Percent of total billed charges,85% of total billed charges,96.53,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.53,50,,6.4,percent of total billed charges,50% of total billed charges,61.68,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,61.68,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.36,38,,58.688,percent of total billed charges,38% of total billed charges,77.22,40,,255.04,percent of total billed charges,40% of total billed charges,61.68,164.09,
lidocaine 0.5% 50 mL preservative-free Soln [FMC],2585560,CDM,250,RC,J2003,HCPCS,OUTPATIENT,50,ML,49.1,29.46,,41.74,85,,33.392,Percent of total billed charges,85% of total billed charges,24.55,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.55,50,,5.6,percent of total billed charges,50% of total billed charges,17.26,35.15,,1180.36,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.66,38,,14.928,percent of total billed charges,38% of total billed charges,15.69,31.95,,1477.76,percent of total billed charges,31.95% of total billed charges,15.69,87.86,
lidocaine 0.5% 50 mL preservative-free Soln [FMC],2585560,CDM,250,RC,J2003,HCPCS,OUTPATIENT,50,ML,16.85,10.11,,14.32,85,,11.456,Percent of total billed charges,85% of total billed charges,8.43,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.43,50,,17.2,percent of total billed charges,50% of total billed charges,5.92,35.15,,1180.36,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.4,38,,5.12,percent of total billed charges,38% of total billed charges,5.38,31.95,,1477.76,percent of total billed charges,31.95% of total billed charges,5.38,87.86,
Dextrose 20% in Water IV Sol 500 mL [FMC],2585586,CDM,250,RC,,,OUTPATIENT,500,ML,44.5,26.7,,37.83,85,,30.264,Percent of total billed charges,85% of total billed charges,22.25,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.25,50,,11.6,percent of total billed charges,50% of total billed charges,14.22,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,14.22,31.95,,1180.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.91,38,,13.528,percent of total billed charges,38% of total billed charges,17.8,40,,1477.76,percent of total billed charges,40% of total billed charges,14.22,37.83,
bupivacaine 0.75%-D8.25% preservative-free Sol [FMC],2585602,CDM,250,RC,,,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,5.6,percent of total billed charges,50% of total billed charges,3.83,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,163.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,204.48,percent of total billed charges,40% of total billed charges,3.83,10.2,
bupivacaine 0.75%-D8.25% preservative-free Sol [FMC],2585602,CDM,250,RC,,,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,16.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,32.336,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,836.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,29.392,percent of total billed charges,40% of total billed charges,3.83,10.2,
bupivacaine 0.75%-D8.25% preservative-free Sol [FMC],2585602,CDM,250,RC,,,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,16,percent of total billed charges,50% of total billed charges,3.83,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,83.84,percent of total billed charges,40% of total billed charges,3.83,10.2,
onabotulinumtoxinA 200 units REC [FMC],2585677,CDM,250,RC,J0585,HCPCS,OUTPATIENT,1,EA,4095,2457,,3480.75,85,,2784.6,Percent of total billed charges,85% of total billed charges,8.73,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.73,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,1439.39,35.15,,100.448,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,100.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1556.1,38,,1244.88,percent of total billed charges,38% of total billed charges,1308.35,31.95,,125.76,percent of total billed charges,31.95% of total billed charges,8.73,3480.75,
chlordiazePOXIDE 10 mg Cap [FMC],2585719,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,3.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,100.448,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,100.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,125.76,percent of total billed charges,40% of total billed charges,1.28,3.4,
phenol topical 89% Swab [FMC],2585727,CDM,250,RC,,,OUTPATIENT,1,EA,17.74,10.644,,15.08,85,,12.064,Percent of total billed charges,85% of total billed charges,8.87,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.87,50,,3.6,percent of total billed charges,50% of total billed charges,5.67,31.95,,1172.184,percent of total billed charges,31.95% of total billed charges,5.67,31.95,,1172.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.74,38,,5.392,percent of total billed charges,38% of total billed charges,7.1,40,,1467.52,percent of total billed charges,40% of total billed charges,5.67,15.08,
pyridoxine 50 mg Tab [FMC],2585735,CDM,250,RC,,,OUTPATIENT,1,EA,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,136.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,728.712,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,728.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,912.32,percent of total billed charges,40% of total billed charges,0.96,2.55,
doxylamine 25 mg Tab [FMC],2585750,CDM,250,RC,,,OUTPATIENT,1,EA,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,136.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,4,percent of total billed charges,50% of total billed charges,1.28,31.95,,844.76,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,844.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1057.6,percent of total billed charges,40% of total billed charges,1.28,3.4,
meropenem 1000 mg REC [FMC],2585768,CDM,250,RC,J2185,HCPCS,OUTPATIENT,1,EA,71.5,42.9,,60.78,85,,48.624,Percent of total billed charges,85% of total billed charges,0.85,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.85,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,25.13,35.15,,844.76,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,844.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.17,38,,21.736,percent of total billed charges,38% of total billed charges,22.84,31.95,,1057.6,percent of total billed charges,31.95% of total billed charges,0.85,87.86,
meropenem 1 gm REC [FMC],2585768,CDM,250,RC,J2185,HCPCS,OUTPATIENT,1,EA,118.38,71.028,,100.62,85,,80.496,Percent of total billed charges,85% of total billed charges,0.85,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.85,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,41.61,35.15,,844.76,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,844.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.98,38,,35.984,percent of total billed charges,38% of total billed charges,37.82,31.95,,1057.6,percent of total billed charges,31.95% of total billed charges,0.85,100.62,
meropenem 1 gm REC [FMC],2585768,CDM,250,RC,J2185,HCPCS,OUTPATIENT,1,EA,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,0.85,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.85,136.6,,34.2,fee schedule,136.60% of BCBS custom fee schedule,27.42,35.15,,418.672,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,23.712,percent of total billed charges,38% of total billed charges,24.92,31.95,,524.16,percent of total billed charges,31.95% of total billed charges,0.85,87.86,
meropenem 1 gm REC [FMC],2585768,CDM,250,RC,J2185,HCPCS,OUTPATIENT,1,EA,115.36,69.216,,98.06,85,,78.448,Percent of total billed charges,85% of total billed charges,0.85,136.6,,34.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.85,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,40.55,35.15,,418.672,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.84,38,,35.072,percent of total billed charges,38% of total billed charges,36.86,31.95,,524.16,percent of total billed charges,31.95% of total billed charges,0.85,98.06,
meropenem 1 gm REC [FMC],2585768,CDM,250,RC,J2185,HCPCS,OUTPATIENT,1,EA,80.75,48.45,,68.64,85,,54.912,Percent of total billed charges,85% of total billed charges,0.85,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.85,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,28.38,35.15,,142.88,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,142.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.69,38,,24.552,percent of total billed charges,38% of total billed charges,25.8,31.95,,178.88,percent of total billed charges,31.95% of total billed charges,0.85,87.86,
loperamide 1 mg/7.5 mL Liq [FMC],2585776,CDM,250,RC,,,OUTPATIENT,7.5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,20.4,percent of total billed charges,50% of total billed charges,0.96,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,209.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
loperamide 1 mg/7.5 mL Liq [FMC],2585776,CDM,250,RC,,,OUTPATIENT,7.5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,20.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,105.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,524.16,percent of total billed charges,40% of total billed charges,0.96,2.55,
loperamide 1 mg/7.5 mL Liq [FMC],2585776,CDM,250,RC,,,OUTPATIENT,7.5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,105.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,0.8,percent of total billed charges,50% of total billed charges,0.96,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,167.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,209.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
tetracaine 1% Sol [FMC],2585784,CDM,250,RC,,,OUTPATIENT,2,ML,295.84,177.504,,251.46,85,,201.168,Percent of total billed charges,85% of total billed charges,147.92,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,147.92,50,,3.2,percent of total billed charges,50% of total billed charges,94.52,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,94.52,31.95,,203.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,112.42,38,,89.936,percent of total billed charges,38% of total billed charges,118.34,40,,254.72,percent of total billed charges,40% of total billed charges,94.52,251.46,
naloxone 4 mg/0.1 mL Nasal Spr [FMC],2585792,CDM,250,RC,,,OUTPATIENT,1,ML,243.75,146.25,,207.19,85,,165.752,Percent of total billed charges,85% of total billed charges,121.88,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,121.88,50,,90.4,percent of total billed charges,50% of total billed charges,77.88,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,77.88,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,92.63,38,,74.104,percent of total billed charges,38% of total billed charges,97.5,40,,524.16,percent of total billed charges,40% of total billed charges,77.88,207.19,
naloxone 4 mg/0.1 mL Nasal Spr [FMC],2585792,CDM,250,RC,,,OUTPATIENT,1,ML,210.6,126.36,,179.01,85,,143.208,Percent of total billed charges,85% of total billed charges,105.3,50,,90.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105.3,50,,0.64,percent of total billed charges,50% of total billed charges,67.29,31.95,,86.648,percent of total billed charges,31.95% of total billed charges,67.29,31.95,,86.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80.03,38,,64.024,percent of total billed charges,38% of total billed charges,84.24,40,,108.48,percent of total billed charges,40% of total billed charges,67.29,179.01,
naloxone 4 mg/0.1 mL Nasal Spr [FMC],2585792,CDM,250,RC,,,OUTPATIENT,1,ML,175.47,105.282,,149.15,85,,119.32,Percent of total billed charges,85% of total billed charges,87.74,50,,0.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.74,50,,20.8,percent of total billed charges,50% of total billed charges,56.06,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,56.06,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.68,38,,53.344,percent of total billed charges,38% of total billed charges,70.19,40,,524.16,percent of total billed charges,40% of total billed charges,56.06,149.15,
levalbuterol 45 mcg/inh Aer [FMC],2585818,CDM,250,RC,,,OUTPATIENT,15,UN,266.14,159.684,,226.22,85,,180.976,Percent of total billed charges,85% of total billed charges,133.07,50,,20.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,133.07,50,,2.8,percent of total billed charges,50% of total billed charges,85.03,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,85.03,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,101.13,38,,80.904,percent of total billed charges,38% of total billed charges,106.46,40,,53.76,percent of total billed charges,40% of total billed charges,85.03,226.22,
albuterol-ipratropium 100 mcg-20 mcg/inh Aer [FMC],2585834,CDM,250,RC,,,OUTPATIENT,4,UN,412.75,247.65,,350.84,85,,280.672,Percent of total billed charges,85% of total billed charges,206.38,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,206.38,50,,27.104,percent of total billed charges,50% of total billed charges,131.87,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,131.87,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,156.85,38,,125.48,percent of total billed charges,38% of total billed charges,165.1,40,,128,percent of total billed charges,40% of total billed charges,131.87,350.84,
budesonide 90 mcg/inh Pow [FMC],2585859,CDM,250,RC,,,OUTPATIENT,1,UN,688.48,413.088,,585.21,85,,468.168,Percent of total billed charges,85% of total billed charges,344.24,50,,27.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,344.24,50,,8.4,percent of total billed charges,50% of total billed charges,219.97,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,219.97,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,261.62,38,,209.296,percent of total billed charges,38% of total billed charges,275.39,40,,53.76,percent of total billed charges,40% of total billed charges,219.97,585.21,
budesonide 90 mcg/inh Pow [FMC],2585859,CDM,250,RC,,,OUTPATIENT,1,UN,770.64,462.384,,655.04,85,,524.032,Percent of total billed charges,85% of total billed charges,385.32,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,385.32,50,,1.2,percent of total billed charges,50% of total billed charges,246.22,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,246.22,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,292.84,38,,234.272,percent of total billed charges,38% of total billed charges,308.26,40,,88.32,percent of total billed charges,40% of total billed charges,246.22,655.04,
ticagrelor 60 mg Tab [FMC],2585875,CDM,250,RC,,,OUTPATIENT,1,EA,25.05,15.03,,21.29,85,,17.032,Percent of total billed charges,85% of total billed charges,12.53,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.53,50,,17.6,percent of total billed charges,50% of total billed charges,8,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,8,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.52,38,,7.616,percent of total billed charges,38% of total billed charges,10.02,40,,53.76,percent of total billed charges,40% of total billed charges,8,21.29,
dantrolene 250 mg IV Inj [FMC},2585891,CDM,250,RC,,,OUTPATIENT,1,EA,11408.18,6844.908,,9696.95,85,,7757.56,Percent of total billed charges,85% of total billed charges,5704.09,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5704.09,50,,12,percent of total billed charges,50% of total billed charges,3644.91,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,3644.91,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4335.11,38,,3468.088,percent of total billed charges,38% of total billed charges,4563.27,40,,88.32,percent of total billed charges,40% of total billed charges,3644.91,9696.95,
heparin 1000 units/mL Inj Sol PURPLE cap 2mL vial [FMC],2585909,CDM,250,RC,J1644,HCPCS,OUTPATIENT,2,ML,37.05,22.23,,31.49,85,,25.192,Percent of total billed charges,85% of total billed charges,0.42,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,13.02,35.15,,42.944,fee schedule,35.15% of LA custom fee schedule,11.84,31.95,,42.944,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.08,38,,11.264,percent of total billed charges,38% of total billed charges,11.84,31.95,,53.76,Fee Schedule,31.95% of LA custom fee schedule,0.42,31.49,
heparin 1000 units/mL Inj Sol PURPLE cap 2mL vial [FMC],2585909,CDM,250,RC,J1644,HCPCS,OUTPATIENT,2,ML,40.56,24.336,,34.48,85,,27.584,Percent of total billed charges,85% of total billed charges,0.42,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,14.26,35.15,,76.68,fee schedule,35.15% of LA custom fee schedule,12.96,31.95,,76.68,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.41,38,,12.328,percent of total billed charges,38% of total billed charges,12.96,31.95,,96,Fee Schedule,31.95% of LA custom fee schedule,0.42,34.48,
heparin 1000 units/mL Inj Sol PURPLE cap 2mL vial [FMC],2585909,CDM,250,RC,J1644,HCPCS,OUTPATIENT,2,ML,53.58,32.148,,45.54,85,,36.432,Percent of total billed charges,85% of total billed charges,0.42,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.42,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,18.83,35.15,,39.616,fee schedule,35.15% of LA custom fee schedule,17.12,31.95,,39.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.36,38,,16.288,percent of total billed charges,38% of total billed charges,17.12,31.95,,49.6,Fee Schedule,31.95% of LA custom fee schedule,0.42,45.54,
rifAXIMin 550 mg Tab UD [FMC],2585925,CDM,250,RC,,,OUTPATIENT,1,EA,193.4,116.04,,164.39,85,,131.512,Percent of total billed charges,85% of total billed charges,96.7,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.7,50,,8.4,percent of total billed charges,50% of total billed charges,61.79,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,61.79,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.49,38,,58.792,percent of total billed charges,38% of total billed charges,77.36,40,,112,percent of total billed charges,40% of total billed charges,61.79,164.39,
labetalol 5 mg/mL IV 4 mL Sol [FMC],2585941,CDM,250,RC,,,OUTPATIENT,4,ML,16.46,9.876,,13.99,85,,11.192,Percent of total billed charges,85% of total billed charges,8.23,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.23,50,,4.8,percent of total billed charges,50% of total billed charges,5.26,31.95,,164.096,percent of total billed charges,31.95% of total billed charges,5.26,31.95,,164.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.25,38,,5,percent of total billed charges,38% of total billed charges,6.58,40,,205.44,percent of total billed charges,40% of total billed charges,5.26,13.99,
labetalol 5 mg/mL IV 4 mL Sol [FMC],2585941,CDM,250,RC,,,OUTPATIENT,4,ML,35.43,21.258,,30.12,85,,24.096,Percent of total billed charges,85% of total billed charges,17.72,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.72,50,,4.4,percent of total billed charges,50% of total billed charges,11.32,31.95,,164.096,percent of total billed charges,31.95% of total billed charges,11.32,31.95,,164.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.46,38,,10.768,percent of total billed charges,38% of total billed charges,14.17,40,,205.44,percent of total billed charges,40% of total billed charges,11.32,30.12,
bupivacaine-meloxicam 400 mg-12 mg/14 mL ERS [FMC],2585966,CDM,250,RC,C9088,HCPCS,OUTPATIENT,14,ML,1095.38,657.228,,931.07,85,,744.856,Percent of total billed charges,85% of total billed charges,1.04,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.04,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,385.03,35.15,,42.944,percent of total billed charges,35.15% of total billed charges,87.86,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,416.24,38,,332.992,percent of total billed charges,38% of total billed charges,349.97,31.95,,53.76,percent of total billed charges,31.95% of total billed charges,1.04,931.07,
cosyntropin 0.25 mg REC [FMC],2585974,CDM,250,RC,J0834,HCPCS,OUTPATIENT,1,EA,312.78,187.668,,265.86,85,,212.688,Percent of total billed charges,85% of total billed charges,49.11,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.11,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,109.94,35.15,,76.68,percent of total billed charges,35.15% of total billed charges,89.14,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,118.86,38,,95.088,percent of total billed charges,38% of total billed charges,99.93,31.95,,96,percent of total billed charges,31.95% of total billed charges,49.11,265.86,
Heparin Lock flush PICC 10u/ml BLUE Syringe 5mL [FMC],2585982,CDM,250,RC,J1642,HCPCS,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.03,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,42.944,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,42.944,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,53.76,Fee Schedule,31.95% of LA custom fee schedule,0.03,10.2,
Heparin Lock flush PICC 10u/ml BLUE Syringe 5mL [FMC],2585982,CDM,250,RC,J1642,HCPCS,OUTPATIENT,5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.03,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,70.544,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,70.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,88.32,Fee Schedule,31.95% of LA custom fee schedule,0.03,10.2,
Amino Acids 4.25% with 5% Dextrose Peripheral TPN Solution (Clinimix) 1000 mL [FMC],2585990,CDM,250,RC,,,OUTPATIENT,1000,ML,150.44,90.264,,127.87,85,,102.296,Percent of total billed charges,85% of total billed charges,75.22,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75.22,50,,3.2,percent of total billed charges,50% of total billed charges,48.07,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,48.07,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57.17,38,,45.736,percent of total billed charges,38% of total billed charges,60.18,40,,67.2,percent of total billed charges,40% of total billed charges,48.07,127.87,
"rabies vaccine, purified chick embryo cell 2.5 intl units REC UD [FMC]",2586006,CDM,250,RC,90685,HCPCS,OUTPATIENT,1,EA,1552.17,931.302,,1319.34,85,,1055.472,Percent of total billed charges,85% of total billed charges,29.56,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.56,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,545.59,35.15,,108.632,fee schedule,35.15% of LA custom fee schedule,495.92,31.95,,108.632,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,589.82,38,,471.856,percent of total billed charges,38% of total billed charges,495.92,31.95,,136,Fee Schedule,31.95% of LA custom fee schedule,29.56,1319.34,
fentaNYL 50 mcg/mL Sol,2586022,CDM,250,RC,J3010,HCPCS,OUTPATIENT,1,ML,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,1.28,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,4.92,35.15,,496.12,percent of total billed charges,35.15% of total billed charges,89.46,31.95,,496.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,4.47,31.95,,621.12,percent of total billed charges,31.95% of total billed charges,1.28,89.46,
sodium chloride 0.9% Sol Inj PF Sterile Diluent 10mL SDV [FMC],2586048,CDM,250,RC,A4216,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.61,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.61,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,557.464,percent of total billed charges,35.15% of total billed charges,90.1,31.95,,557.464,percent of total billed charges,31.95% of total billed charges,0.61,100,,,fee schedule,100% of CMS custom fee schedule,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,697.92,percent of total billed charges,31.95% of total billed charges,0.61,90.1,
bacteriostatic sodium chloride 0.9% Sol Inj Sterile Diluent 30mL MDV [FMC],2586063,CDM,250,RC,J3490,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,16.8,percent of total billed charges,50% of total billed charges,4.22,35.15,,1017.8,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,1017.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1274.24,Fee Schedule,31.95% of LA custom fee schedule,3.83,10.2,
inclisiran 284 mg/1.5 mL Sol [FMC],2586105,CDM,250,RC,J1306,HCPCS,OUTPATIENT,1.5,ML,12675,7605,,10773.75,85,,8619,Percent of total billed charges,85% of total billed charges,18.06,136.6,,16.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.06,136.6,,0.68,fee schedule,136.60% of BCBS custom fee schedule,4455.26,35.15,,1017.8,percent of total billed charges,35.15% of total billed charges,90.1,31.95,,1017.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4816.5,38,,3853.2,percent of total billed charges,38% of total billed charges,4049.66,31.95,,1274.24,percent of total billed charges,31.95% of total billed charges,18.06,10773.75,
denosumab 60 mg/mL Sol [FMC],2586121,CDM,250,RC,J0897,HCPCS,OUTPATIENT,1,ML,6335.71,3801.426,,5385.35,85,,4308.28,Percent of total billed charges,85% of total billed charges,36.39,136.6,,0.68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.39,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,2227,35.15,,1017.8,percent of total billed charges,35.15% of total billed charges,90.1,31.95,,1017.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2407.57,38,,1926.056,percent of total billed charges,38% of total billed charges,2024.26,31.95,,1274.24,percent of total billed charges,31.95% of total billed charges,36.39,5385.35,
denosumab 60 mg/mL Sol [FMC],2586121,CDM,250,RC,J0897,HCPCS,OUTPATIENT,1,ML,6965.86,4179.516,,5920.98,85,,4736.784,Percent of total billed charges,85% of total billed charges,36.39,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.39,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,2448.5,35.15,,532.032,percent of total billed charges,35.15% of total billed charges,90.58,31.95,,891.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2647.03,38,,2117.624,percent of total billed charges,38% of total billed charges,2225.59,31.95,,483.592,percent of total billed charges,31.95% of total billed charges,36.39,5920.98,
ampicillin 2000 mg Inj [FMC],2586154,CDM,250,RC,J0290,HCPCS,OUTPATIENT,1,EA,54.6,32.76,,46.41,85,,37.128,Percent of total billed charges,85% of total billed charges,1.43,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.43,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,19.19,35.15,,56.24,fee schedule,35.15% of LA custom fee schedule,17.44,31.95,,891.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.75,38,,16.6,percent of total billed charges,38% of total billed charges,17.44,31.95,,51.12,Fee Schedule,31.95% of LA custom fee schedule,1.43,46.41,
ampicillin 2000 mg Inj [FMC],2586154,CDM,250,RC,J0290,HCPCS,OUTPATIENT,1,EA,51.72,31.032,,43.96,85,,35.168,Percent of total billed charges,85% of total billed charges,1.43,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.43,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,18.18,35.15,,92.232,fee schedule,35.15% of LA custom fee schedule,16.52,31.95,,918.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.65,38,,15.72,percent of total billed charges,38% of total billed charges,16.52,31.95,,83.84,Fee Schedule,31.95% of LA custom fee schedule,1.43,43.96,
leuprolide 7.5 mg/month Kit [FMC],2586162,CDM,250,RC,J9217,HCPCS,OUTPATIENT,1,EA,1100,660,,935,85,,748,Percent of total billed charges,85% of total billed charges,250.47,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.47,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,92.232,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,918.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,418,38,,334.4,percent of total billed charges,38% of total billed charges,351.45,31.95,,83.84,Fee Schedule,31.95% of LA custom fee schedule,250.47,935,
Vancomycin 750 mg IV Inj [FMC],2586170,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,29.56,17.736,,25.13,85,,20.104,Percent of total billed charges,85% of total billed charges,3.14,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,10.39,35.15,,1047.96,fee schedule,35.15% of LA custom fee schedule,9.44,31.95,,1047.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.23,38,,8.984,percent of total billed charges,38% of total billed charges,9.44,31.95,,1312,Fee Schedule,31.95% of LA custom fee schedule,3.14,25.13,
Vancomycin 750 mg IV Inj [FMC],2586170,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,37.05,22.23,,31.49,85,,25.192,Percent of total billed charges,85% of total billed charges,3.14,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,24.8,fee schedule,136.60% of BCBS custom fee schedule,13.02,35.15,,1007.064,fee schedule,35.15% of LA custom fee schedule,11.84,31.95,,1007.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.08,38,,11.264,percent of total billed charges,38% of total billed charges,11.84,31.95,,1260.8,Fee Schedule,31.95% of LA custom fee schedule,3.14,31.49,
Vancomycin 750 mg IV Inj [FMC],2586170,CDM,250,RC,J3370,HCPCS,OUTPATIENT,1,EA,35.1,21.06,,29.84,85,,23.872,Percent of total billed charges,85% of total billed charges,3.14,136.6,,24.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,12.34,35.15,,158.472,fee schedule,35.15% of LA custom fee schedule,11.21,31.95,,158.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.34,38,,10.672,percent of total billed charges,38% of total billed charges,11.21,31.95,,198.4,Fee Schedule,31.95% of LA custom fee schedule,3.14,29.84,
leuprolide 22.5 mg/3 months Kit [FMC],2586188,CDM,250,RC,J9217,HCPCS,OUTPATIENT,1,EA,3300.02,1980.012,,2805.02,85,,2244.016,Percent of total billed charges,85% of total billed charges,250.47,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.47,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,1159.96,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,1054.36,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1254.01,38,,1003.208,percent of total billed charges,38% of total billed charges,1054.36,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,250.47,2805.02,
cefTRIAXone 2 g Inj [FMC],2586196,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,296.75,178.05,,252.24,85,,201.792,Percent of total billed charges,85% of total billed charges,0.71,136.6,,13.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,16.344,fee schedule,136.60% of BCBS custom fee schedule,104.31,35.15,,102.24,fee schedule,35.15% of LA custom fee schedule,94.81,31.95,,102.24,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,112.77,38,,90.216,percent of total billed charges,38% of total billed charges,94.81,31.95,,128,Fee Schedule,31.95% of LA custom fee schedule,0.71,252.24,
cefTRIAXone 2 g Inj [FMC],2586196,CDM,250,RC,J0696,HCPCS,OUTPATIENT,1,EA,297.08,178.248,,252.52,85,,202.016,Percent of total billed charges,85% of total billed charges,0.71,136.6,,16.344,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,104.42,35.15,,76.68,fee schedule,35.15% of LA custom fee schedule,94.92,31.95,,76.68,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,112.89,38,,90.312,percent of total billed charges,38% of total billed charges,94.92,31.95,,96,Fee Schedule,31.95% of LA custom fee schedule,0.71,252.52,
leuprolide 45 mg/6 months Kit [FMC],2586204,CDM,250,RC,J9217,HCPCS,OUTPATIENT,1,EA,6500,3900,,5525,85,,4420,Percent of total billed charges,85% of total billed charges,250.47,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.47,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,2284.75,35.15,,2011.576,fee schedule,35.15% of LA custom fee schedule,2076.75,31.95,,2011.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,2470,38,,1976,percent of total billed charges,38% of total billed charges,2076.75,31.95,,2518.4,Fee Schedule,31.95% of LA custom fee schedule,250.47,5525,
DOXOrubicin 50 mg REC [FMC],2586220,CDM,250,RC,J9000,HCPCS,OUTPATIENT,1,EA,1025.82,615.492,,871.95,85,,697.56,Percent of total billed charges,85% of total billed charges,4.03,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.03,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,360.58,35.15,,424.296,fee schedule,35.15% of LA custom fee schedule,327.75,31.95,,424.296,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,389.81,38,,311.848,percent of total billed charges,38% of total billed charges,327.75,31.95,,531.2,Fee Schedule,31.95% of LA custom fee schedule,4.03,871.95,
sevelamer carbonate 800 mg Tab [FMC],2586238,CDM,250,RC,,,OUTPATIENT,1,EA,19.81,11.886,,16.84,85,,13.472,Percent of total billed charges,85% of total billed charges,9.91,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.91,50,,9.6,percent of total billed charges,50% of total billed charges,6.33,31.95,,1007.064,percent of total billed charges,31.95% of total billed charges,6.33,31.95,,1007.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.53,38,,6.024,percent of total billed charges,38% of total billed charges,7.92,40,,1260.8,percent of total billed charges,40% of total billed charges,6.33,16.84,
bacitracin/neomycin/polymyxin B Top Oint 14g [FMC],2586253,CDM,250,RC,,,OUTPATIENT,14,EA,13.81,8.286,,11.74,85,,9.392,Percent of total billed charges,85% of total billed charges,6.91,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.91,50,,34.8,percent of total billed charges,50% of total billed charges,4.41,31.95,,756.576,percent of total billed charges,31.95% of total billed charges,4.41,31.95,,756.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.25,38,,4.2,percent of total billed charges,38% of total billed charges,5.52,40,,947.2,percent of total billed charges,40% of total billed charges,4.41,11.74,
norepinephrine 4 mg/250 mL-D5% Premix [FMC],2586261,CDM,250,RC,,,OUTPATIENT,250,ML,97.5,58.5,,82.88,85,,66.304,Percent of total billed charges,85% of total billed charges,48.75,50,,34.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48.75,50,,5.6,percent of total billed charges,50% of total billed charges,31.15,31.95,,325.888,percent of total billed charges,31.95% of total billed charges,31.15,31.95,,325.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.05,38,,29.64,percent of total billed charges,38% of total billed charges,39,40,,408,percent of total billed charges,40% of total billed charges,31.15,82.88,
magnesium sulfate 50% Inj Sol 20 mL [FMC],2586279,CDM,250,RC,J3475,HCPCS,OUTPATIENT,20,ML,14.78,8.868,,12.56,85,,10.048,Percent of total billed charges,85% of total billed charges,1.15,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,5.2,35.15,,655.36,percent of total billed charges,35.15% of total billed charges,90.58,31.95,,655.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.62,38,,4.496,percent of total billed charges,38% of total billed charges,4.72,31.95,,820.48,percent of total billed charges,31.95% of total billed charges,1.15,90.58,
magnesium sulfate 50% Inj Sol 20 mL [FMC],2586279,CDM,250,RC,J3475,HCPCS,OUTPATIENT,20,ML,30.69,18.414,,26.09,85,,20.872,Percent of total billed charges,85% of total billed charges,1.15,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,10.79,35.15,,1201.568,percent of total billed charges,35.15% of total billed charges,91.06,31.95,,918.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.66,38,,9.328,percent of total billed charges,38% of total billed charges,9.81,31.95,,1092.176,percent of total billed charges,31.95% of total billed charges,1.15,91.06,
magnesium sulfate 50% Inj Sol 20 mL [FMC],2586279,CDM,250,RC,J3475,HCPCS,OUTPATIENT,20,ML,15.68,9.408,,13.33,85,,10.664,Percent of total billed charges,85% of total billed charges,1.15,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,5.51,35.15,,164.504,percent of total billed charges,35.15% of total billed charges,92.66,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.96,38,,4.768,percent of total billed charges,38% of total billed charges,5.01,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,1.15,92.66,
magnesium sulfate 50% Inj Sol 10 mL [FMC],2586295,CDM,250,RC,J3475,HCPCS,OUTPATIENT,10,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.15,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.15,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,894.6,percent of total billed charges,35.15% of total billed charges,92.66,31.95,,894.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,1120,percent of total billed charges,31.95% of total billed charges,1.15,92.66,
niCARdipine 2.5 mg/mL 10mL Sol [FMC],2586303,CDM,250,RC,J2404,HCPCS,OUTPATIENT,10,ML,99.53,59.718,,84.6,85,,67.68,Percent of total billed charges,85% of total billed charges,49.77,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,49.77,50,,6,percent of total billed charges,50% of total billed charges,34.98,35.15,,1121.064,percent of total billed charges,35.15% of total billed charges,92.66,31.95,,1121.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.82,38,,30.256,percent of total billed charges,38% of total billed charges,31.8,31.95,,1403.52,percent of total billed charges,31.95% of total billed charges,31.8,92.66,
vancomycin 1 g/200 mL IV Sol [FMC],2586311,CDM,250,RC,J3370,HCPCS,OUTPATIENT,200,ML,62.4,37.44,,53.04,85,,42.432,Percent of total billed charges,85% of total billed charges,3.14,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.14,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,21.93,35.15,,838.624,fee schedule,35.15% of LA custom fee schedule,19.94,31.95,,838.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,23.71,38,,18.968,percent of total billed charges,38% of total billed charges,19.94,31.95,,1049.92,Fee Schedule,31.95% of LA custom fee schedule,3.14,53.04,
"Influenza virus vaccine, inactivated Flublok [FMC]",2586345,CDM,250,RC,,,OUTPATIENT,0.5,ML,105.17,63.102,,89.39,85,,71.512,Percent of total billed charges,85% of total billed charges,52.59,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.59,50,,76.8,percent of total billed charges,50% of total billed charges,33.6,31.95,,559.768,percent of total billed charges,31.95% of total billed charges,33.6,31.95,,559.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.96,38,,31.968,percent of total billed charges,38% of total billed charges,42.07,40,,700.8,percent of total billed charges,40% of total billed charges,33.6,89.39,
"influenza virus vaccine, Fluzone inactivated preservative-free trivalent Sus [FMC]",2586360,CDM,250,RC,,,OUTPATIENT,1,ML,161.3,96.78,,137.11,85,,109.688,Percent of total billed charges,85% of total billed charges,80.65,50,,76.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,80.65,50,,1.2,percent of total billed charges,50% of total billed charges,51.54,31.95,,881.824,percent of total billed charges,31.95% of total billed charges,51.54,31.95,,881.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,61.29,38,,49.032,percent of total billed charges,38% of total billed charges,64.52,40,,1104,percent of total billed charges,40% of total billed charges,51.54,137.11,
albumin human 5% Sol,2586386,CDM,250,RC,P9045,HCPCS,OUTPATIENT,250,ML,179.4,107.64,,152.49,85,,121.992,Percent of total billed charges,85% of total billed charges,79.76,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.76,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,63.06,35.15,,1789.2,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,1789.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.17,38,,54.536,percent of total billed charges,38% of total billed charges,57.32,31.95,,2240,percent of total billed charges,31.95% of total billed charges,57.32,152.49,
sodium phosphate 3 mmol/mL Inj 5mL Sol [FMC],2586394,CDM,250,RC,,,OUTPATIENT,5,ML,62.95,37.77,,53.51,85,,42.808,Percent of total billed charges,85% of total billed charges,31.48,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.48,50,,80.8,percent of total billed charges,50% of total billed charges,20.11,31.95,,838.624,percent of total billed charges,31.95% of total billed charges,20.11,31.95,,838.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.92,38,,19.136,percent of total billed charges,38% of total billed charges,25.18,40,,1049.92,percent of total billed charges,40% of total billed charges,20.11,53.51,
sodium phosphate 3 mmol/mL Inj 5mL Sol [FMC],2586394,CDM,250,RC,,,OUTPATIENT,5,ML,66.42,39.852,,56.46,85,,45.168,Percent of total billed charges,85% of total billed charges,33.21,50,,80.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.21,50,,31.2,percent of total billed charges,50% of total billed charges,21.22,31.95,,9.84,percent of total billed charges,31.95% of total billed charges,21.22,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.24,38,,20.192,percent of total billed charges,38% of total billed charges,26.57,40,,8.944,percent of total billed charges,40% of total billed charges,21.22,56.46,
sodium chloride nasal 0.65% Spr [FMC},2586402,CDM,250,RC,,,OUTPATIENT,44,UN,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,21.6,percent of total billed charges,50% of total billed charges,1.92,31.95,,496.12,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,496.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,621.12,percent of total billed charges,40% of total billed charges,1.92,5.1,
nystatin 100000 units/mL Sus 473 BTL [FMC},2586410,CDM,250,RC,,,OUTPATIENT,5,ML,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,63.6,percent of total billed charges,50% of total billed charges,0.96,31.95,,237.456,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,237.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,0.912,percent of total billed charges,38% of total billed charges,1.2,40,,297.28,percent of total billed charges,40% of total billed charges,0.96,2.55,
hylan G-F 20 16 mg/2 mL Sol [FMC],2586436,CDM,250,RC,J7325,HCPCS,OUTPATIENT,2,ML,1780.5,1068.3,,1513.43,85,,1210.744,Percent of total billed charges,85% of total billed charges,13.18,136.6,,63.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,13.18,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,625.85,35.15,,155.92,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,155.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,676.59,38,,541.272,percent of total billed charges,38% of total billed charges,568.87,31.95,,195.2,percent of total billed charges,31.95% of total billed charges,13.18,1513.43,
"bupivacaine-epinephrine 0.5%-1:200,000 preservative-free Sol 30mL  [FMC]",2586451,CDM,250,RC,,,OUTPATIENT,30,ML,23.05,13.83,,19.59,85,,15.672,Percent of total billed charges,85% of total billed charges,11.53,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.53,50,,2.4,percent of total billed charges,50% of total billed charges,7.36,31.95,,2095.92,percent of total billed charges,31.95% of total billed charges,7.36,31.95,,2095.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.76,38,,7.008,percent of total billed charges,38% of total billed charges,9.22,40,,2624,percent of total billed charges,40% of total billed charges,7.36,19.59,
dexamethasone-tobramycin Opth 0.1%-0.3% Susp [FMC],2587790,CDM,250,RC,,,OUTPATIENT,2.5,EA,246.88,148.128,,209.85,85,,167.88,Percent of total billed charges,85% of total billed charges,123.44,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,123.44,50,,18,percent of total billed charges,50% of total billed charges,78.88,31.95,,480.528,percent of total billed charges,31.95% of total billed charges,78.88,31.95,,480.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,93.81,38,,75.048,percent of total billed charges,38% of total billed charges,98.75,40,,601.6,percent of total billed charges,40% of total billed charges,78.88,209.85,
dexamethasone-tobramycin Opth 0.1%-0.3% Susp [FMC],2587790,CDM,250,RC,,,OUTPATIENT,2.5,EA,197.21,118.326,,167.63,85,,134.104,Percent of total billed charges,85% of total billed charges,98.61,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,98.61,50,,17.2,percent of total billed charges,50% of total billed charges,63.01,31.95,,29.528,percent of total billed charges,31.95% of total billed charges,63.01,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,74.94,38,,59.952,percent of total billed charges,38% of total billed charges,78.88,40,,26.84,percent of total billed charges,40% of total billed charges,63.01,167.63,
dexamethasone-tobramycin Opth 0.1%-0.3% Susp [FMC],2587790,CDM,250,RC,,,OUTPATIENT,2.5,EA,235.82,141.492,,200.45,85,,160.36,Percent of total billed charges,85% of total billed charges,117.91,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,117.91,50,,25.6,percent of total billed charges,50% of total billed charges,75.34,31.95,,73.672,percent of total billed charges,31.95% of total billed charges,75.34,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,89.61,38,,71.688,percent of total billed charges,38% of total billed charges,94.33,40,,66.968,percent of total billed charges,40% of total billed charges,75.34,200.45,
dexamethasone-tobramycin Opth 0.1%-0.3% Susp [FMC],2587790,CDM,250,RC,,,OUTPATIENT,2.5,EA,147.94,88.764,,125.75,85,,100.6,Percent of total billed charges,85% of total billed charges,73.97,50,,25.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.97,50,,18.4,percent of total billed charges,50% of total billed charges,47.27,31.95,,73.672,percent of total billed charges,31.95% of total billed charges,47.27,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,56.22,38,,44.976,percent of total billed charges,38% of total billed charges,59.18,40,,66.968,percent of total billed charges,40% of total billed charges,47.27,125.75,
dexamethasone-tobramycin Opth 0.1%-0.3% Susp [FMC],2587790,CDM,250,RC,,,OUTPATIENT,2.5,EA,324.25,194.55,,275.61,85,,220.488,Percent of total billed charges,85% of total billed charges,162.13,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,162.13,50,,18.4,percent of total billed charges,50% of total billed charges,103.6,31.95,,73.672,percent of total billed charges,31.95% of total billed charges,103.6,31.95,,924.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,123.22,38,,98.576,percent of total billed charges,38% of total billed charges,129.7,40,,66.968,percent of total billed charges,40% of total billed charges,103.6,275.61,
3000CC STERILE WATER,2620607,CDM,250,RC,,,OUTPATIENT,,,126.9,76.14,,107.87,85,,86.296,Percent of total billed charges,85% of total billed charges,63.45,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,63.45,50,,17.2,percent of total billed charges,50% of total billed charges,40.54,31.95,,73.672,percent of total billed charges,31.95% of total billed charges,40.54,31.95,,941.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.22,38,,38.576,percent of total billed charges,38% of total billed charges,50.76,40,,66.968,percent of total billed charges,40% of total billed charges,40.54,107.87,
Dextrose 5% in Water IV Sol 100 mL [FMC],2623239,CDM,250,RC,,,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,99.6,percent of total billed charges,50% of total billed charges,11.5,31.95,,73.672,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,989.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,66.968,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% in Water IV Sol 100 mL [FMC],2623239,CDM,250,RC,,,OUTPATIENT,100,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,99.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,68.8,percent of total billed charges,50% of total billed charges,11.5,31.95,,108.264,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,1009.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,98.408,percent of total billed charges,40% of total billed charges,11.5,30.6,
SODIUM CLORIDE 9% 1000CC POUR,2625002,CDM,258,RC,,,OUTPATIENT,,,30.9,18.54,,26.27,85,,21.016,Percent of total billed charges,85% of total billed charges,15.45,50,,68.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.45,50,,6,percent of total billed charges,50% of total billed charges,9.87,31.95,,108.264,percent of total billed charges,31.95% of total billed charges,9.87,31.95,,1010.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.74,38,,9.392,percent of total billed charges,38% of total billed charges,12.36,40,,98.408,percent of total billed charges,40% of total billed charges,9.87,26.27,
SODIUM CLORIDE 9% 500CC POUR,2625010,CDM,258,RC,,,OUTPATIENT,,,26.7,16.02,,22.7,85,,18.16,Percent of total billed charges,85% of total billed charges,13.35,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.35,50,,2.8,percent of total billed charges,50% of total billed charges,8.53,31.95,,108.264,percent of total billed charges,31.95% of total billed charges,8.53,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.15,38,,8.12,percent of total billed charges,38% of total billed charges,10.68,40,,98.408,percent of total billed charges,40% of total billed charges,8.53,22.7,
Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L intravenous solution [FMC],2645802,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,16,percent of total billed charges,50% of total billed charges,11.5,31.95,,108.264,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,98.408,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L intravenous solution [FMC],2645802,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,26.8,percent of total billed charges,50% of total billed charges,11.5,31.95,,108.264,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,98.408,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L intravenous solution [FMC],2645802,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,26.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,1.184,percent of total billed charges,50% of total billed charges,11.5,31.95,,108.264,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,98.408,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [FMC],2645810,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,1.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,8.104,percent of total billed charges,50% of total billed charges,11.5,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,149.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [FMC],2645810,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,8.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,30.4,percent of total billed charges,50% of total billed charges,11.5,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,149.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [FMC],2645810,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,30.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,12.8,percent of total billed charges,50% of total billed charges,11.5,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,149.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% with KCl 20 mEq/l IV Sol 1000 mL [FMC],2647253,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,41.2,percent of total billed charges,50% of total billed charges,11.5,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,149.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% with KCl 20 mEq/l IV Sol 1000 mL [FMC],2647253,CDM,250,RC,,,OUTPATIENT,1000,ML,38.06,22.836,,32.35,85,,25.88,Percent of total billed charges,85% of total billed charges,19.03,50,,41.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.03,50,,98.4,percent of total billed charges,50% of total billed charges,12.16,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,12.16,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.46,38,,11.568,percent of total billed charges,38% of total billed charges,15.22,40,,149.528,percent of total billed charges,40% of total billed charges,12.16,32.35,
Sodium Chloride 0.9% with KCl 20 mEq/l IV Sol 1000 mL [FMC],2647253,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,98.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,56.4,percent of total billed charges,50% of total billed charges,11.5,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,149.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
Sodium Chloride 0.9% with KCl 20 mEq/l IV Sol 1000 mL [FMC],2647253,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,56.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,189.176,percent of total billed charges,50% of total billed charges,11.5,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,149.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
"96413 CHEMO ADMIN, IV INFUSION, UP TO 1 HOUR CHARGE",2696417,CDM,260,RC,96413,HCPCS,OUTPATIENT,,,899,539.4,,764.15,85,,611.32,Percent of total billed charges,85% of total billed charges,558.19,136.6,,189.176,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,558.19,136.6,,210.24,fee schedule,136.60% of BCBS custom fee schedule,316,35.15,,164.504,fee schedule,35.15% of LA custom fee schedule,287.23,31.95,,77.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,9.12,case rate,pays based on per visit rate,287.23,31.95,,149.528,Fee Schedule,31.95% of LA custom fee schedule,175,764.15,
"96415 CHEMO ADMIN, IV INFUSION, EA ADDL HOUR CHARGE",2696458,CDM,260,RC,96415,HCPCS,OUTPATIENT,,,135,81,,114.75,85,,91.8,Percent of total billed charges,85% of total billed charges,128.62,136.6,,210.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,128.62,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,47.45,35.15,,164.504,fee schedule,35.15% of LA custom fee schedule,43.13,31.95,,77.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,10.64,case rate,pays based on per visit rate,43.13,31.95,,149.528,Fee Schedule,31.95% of LA custom fee schedule,43.13,175,
STAT-LOCK CV PLUS STABILIZATION DEVICE,2701928,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,6,percent of total billed charges,50% of total billed charges,9.59,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,10.944,percent of total billed charges,38% of total billed charges,12,40,,149.528,percent of total billed charges,40% of total billed charges,9.59,25.5,
CATHETER COUDE 18FR 30CC,2701951,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,42.8,percent of total billed charges,50% of total billed charges,11.18,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,10.944,percent of total billed charges,38% of total billed charges,14,40,,149.528,percent of total billed charges,40% of total billed charges,11.18,29.75,
Dextrose 10% in Water IV Sol 1000 mL [FMC],2722353,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,42.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,3.2,percent of total billed charges,50% of total billed charges,11.5,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,149.528,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 10% in Water IV Sol 1000 mL [FMC],2722353,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,4.8,percent of total billed charges,50% of total billed charges,11.5,31.95,,386.928,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,12.16,percent of total billed charges,38% of total billed charges,14.4,40,,351.704,percent of total billed charges,40% of total billed charges,11.5,30.6,
Dextrose 10% in Water IV Sol 1000 mL [FMC],2722353,CDM,250,RC,,,OUTPATIENT,1000,ML,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,2,percent of total billed charges,50% of total billed charges,11.5,31.95,,386.928,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,6.688,percent of total billed charges,38% of total billed charges,14.4,40,,351.704,percent of total billed charges,40% of total billed charges,11.5,30.6,
NITROUS OXIDE/HR,2738953,CDM,370,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,2.8,percent of total billed charges,50% of total billed charges,12.78,31.95,,386.928,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,6.384,percent of total billed charges,38% of total billed charges,16,40,,351.704,percent of total billed charges,40% of total billed charges,12.78,34,
DECLOGGER ORANGE FOR ''''G'''' TUBE,2752004,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,150.328,percent of total billed charges,50% of total billed charges,7.03,31.95,,386.928,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,1920,percent of total billed charges,38% of total billed charges,8.8,40,,351.704,percent of total billed charges,40% of total billed charges,7.03,18.7,
BABY DIAPER SZ 2 SMALL,2752186,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,150.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,1.6,percent of total billed charges,50% of total billed charges,6.71,31.95,,289.64,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,1440,percent of total billed charges,38% of total billed charges,8.4,40,,263.272,percent of total billed charges,40% of total billed charges,6.71,17.85,
ROOM/BED: Private,3020001,CDM,110,RC,,,INPATIENT,,,765,459,,1300,100,,,case rate,pays based on per day rate,748.94,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,748.94,50,,25.392,percent of total billed charges,50% of total billed charges,,,,289.64,other,Not separately reimbursable,,31.95,,78.728,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2400,38,,5.168,percent of total billed charges,38% of total billed charges,,,,263.272,other,Not separately reimbursable,748.94,2400,
ROOM/BED: Swingbed,3020002,CDM,22,RC,,,INPATIENT,,,765,459,,,,,,other,Not separately reimbursable,,,,25.392,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,18,other,Not separately reimbursable,,,,289.64,other,Not separately reimbursable,,31.95,,78.728,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,31.92,other,Not separately reimbursable,,,,263.272,other,Not separately reimbursable,749.94,2401,
ROOM/BED: Observation,3020003,CDM,762,RC,G0378,HCPCS,OUTPATIENT,,,70,42,,1300,100,,,case rate,pays based on per day rate,47.99,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,47.99,136.6,,87.2,fee schedule,136.60% of BCBS custom fee schedule,24.61,35.15,,625.672,fee schedule,35.15% of LA custom fee schedule,22.37,31.95,,78.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1800,38,,31.92,percent of total billed charges,38% of total billed charges,22.37,31.95,,568.712,Fee Schedule,31.95% of LA custom fee schedule,750.94,2402,
ROOM/BED: Inpatient Rehab,3020004,CDM,24,RC,,,INPATIENT,,,765,459,,,,,,other,Not separately reimbursable,,,,87.2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,46.4,other,Not separately reimbursable,,,,289.64,other,Not separately reimbursable,,31.95,,78.728,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,88.16,other,Not separately reimbursable,,,,263.272,other,Not separately reimbursable,751.94,2403,
96360 HYDRATION (1ST HR) CHARGE,3020005,CDM,260,RC,96360,HCPCS,OUTPATIENT,,,303,181.8,59,257.55,85,,206.04,Percent of total billed charges,85% of total billed charges,206.2,136.6,,46.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,206.2,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,106.5,35.15,,289.64,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,364.8,case rate,pays based on per visit rate,96.81,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,752.94,2404,
"96360 - Hydration, first hour",3020005,CDM,260,RC,96360,HCPCS,OUTPATIENT,,,303,181.8,59,257.55,85,,206.04,Percent of total billed charges,85% of total billed charges,206.2,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,206.2,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,106.5,35.15,,289.64,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,18.544,case rate,pays based on per visit rate,96.81,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,753.94,2405,
96361 HYDRATION ADDITIONAL HOUR CHARGE,3020006,CDM,260,RC,96361,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,66.25,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.25,136.6,,26.8,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,289.64,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,6.384,case rate,pays based on per visit rate,52.72,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,754.94,2406,
"96361 - Hydration, each additional hour",3020006,CDM,260,RC,96361,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,66.25,136.6,,26.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.25,136.6,,30.4,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,386.928,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,1920,case rate,pays based on per visit rate,52.72,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,755.94,2407,
96365 IV INF TX/PX/DX  1ST HR CHARGE,3020007,CDM,260,RC,96365,HCPCS,OUTPATIENT,,,514,308.4,59,436.9,85,,349.52,Percent of total billed charges,85% of total billed charges,161.95,136.6,,30.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,44,fee schedule,136.60% of BCBS custom fee schedule,180.67,35.15,,386.928,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,31.92,case rate,pays based on per visit rate,164.22,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,756.94,2408,
"96365 - IV tx, first hour",3020007,CDM,260,RC,96365,HCPCS,OUTPATIENT,,,514,308.4,59,436.9,85,,349.52,Percent of total billed charges,85% of total billed charges,161.95,136.6,,44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,180.67,35.15,,164.504,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,5.168,case rate,pays based on per visit rate,164.22,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,757.94,2409,
96366 IV INF TX/PX/DX  ADD HR CHARGE,3020008,CDM,260,RC,96366,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,161.95,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,164.504,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,48.64,case rate,pays based on per visit rate,52.72,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,758.94,2410,
"96366 - IV tx, each additional hour",3020008,CDM,260,RC,96366,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,161.95,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,42.8,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,386.928,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,48.64,case rate,pays based on per visit rate,52.72,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,759.94,2411,
96367 IV ADD SEQ INF SAME IV ACCESS CHARGE,3020009,CDM,260,RC,96367,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,161.95,136.6,,42.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,386.928,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,78.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,48.64,case rate,pays based on per visit rate,52.72,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,760.94,2412,
"96367 - IV tx, sequential infusion",3020009,CDM,260,RC,96367,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,161.95,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,60.064,percent of total billed charges,35.15% of total billed charges,93.29,31.95,,60.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,190.304,case rate,pays based on per visit rate,52.72,31.95,,75.2,percent of total billed charges,31.95% of total billed charges,761.94,2413,
96368 IV CONCURRENT INFUSION,3020010,CDM,260,RC,96368,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,161.95,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,67.2,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,33.184,percent of total billed charges,35.15% of total billed charges,93.93,31.95,,78.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,243.2,case rate,pays based on per visit rate,52.72,31.95,,30.16,percent of total billed charges,31.95% of total billed charges,762.94,2414,
"96368 - IV tx, concurrent infusion",3020010,CDM,260,RC,96368,HCPCS,OUTPATIENT,,,165,99,59,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,161.95,136.6,,67.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,58,35.15,,14.056,percent of total billed charges,35.15% of total billed charges,93.93,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,41.648,case rate,pays based on per visit rate,52.72,31.95,,17.6,percent of total billed charges,31.95% of total billed charges,763.94,2415,
M0243 ADMIN CASIVIRIMAB AND IMDEVIMAB,3020053,CDM,771,RC,M0243,HCPCS,OUTPATIENT,,,675,405,,573.75,85,,459,Percent of total billed charges,85% of total billed charges,424.48,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,424.48,136.6,,49.6,fee schedule,136.60% of BCBS custom fee schedule,215.66,31.95,,33.184,percent of total billed charges,31.95% of total billed charges,215.66,31.95,,79.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,9.12,case rate,pays based on per visit rate,270,40,,30.16,percent of total billed charges,40% of total billed charges,764.94,2416,
M0245 BAMLANIVIMAB AND ETESEVIMAB,3020055,CDM,771,RC,M0245,HCPCS,OUTPATIENT,,,675,405,,573.75,85,,459,Percent of total billed charges,85% of total billed charges,424.48,136.6,,49.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,424.48,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,215.66,31.95,,35.152,percent of total billed charges,31.95% of total billed charges,215.66,31.95,,80.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,590.064,case rate,pays based on per visit rate,270,40,,31.952,percent of total billed charges,40% of total billed charges,765.94,2417,
M0247 SOTOVIMAB INFUSION,3020057,CDM,771,RC,M0247,HCPCS,OUTPATIENT,,,675,405,,573.75,85,,459,Percent of total billed charges,85% of total billed charges,424.48,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,424.48,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,215.66,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,215.66,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,590.064,case rate,pays based on per visit rate,270,40,,151.04,percent of total billed charges,40% of total billed charges,766.94,2418,
TELEHEALTH SITE FEE,3020110,CDM,780,RC,Q3014,HCPCS,OUTPATIENT,,,72,43.2,,61.2,85,,48.96,Percent of total billed charges,85% of total billed charges,36,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36,50,,144,percent of total billed charges,50% of total billed charges,23,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,23,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,566.96,other,Not separately reimbursable,28.8,40,,19.2,percent of total billed charges,40% of total billed charges,767.94,2419,
ABORh,3027307,CDM,302,RC,86900,HCPCS,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,13.91,136.6,,144,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,13.91,136.6,,28.4,fee schedule,136.60% of BCBS custom fee schedule,3.29,110,,49.84,fee schedule,110% of LA custom fee schedule,2.99,100,,49.84,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.46,38,,1976,percent of total billed charges,38% of total billed charges,2.99,100,,62.4,Fee Schedule,100% of LA custom fee schedule,768.94,2420,
Compatible,3029949,CDM,302,RC,86920,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,43.68,136.6,,28.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.68,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,56.52,110,,49.84,fee schedule,110% of LA custom fee schedule,51.38,100,,49.84,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.9,38,,167.808,percent of total billed charges,38% of total billed charges,51.38,100,,62.4,Fee Schedule,100% of LA custom fee schedule,769.94,2421,
Compatibility,3029949,CDM,302,RC,86920,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,43.68,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.68,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,56.52,110,,23.768,fee schedule,110% of LA custom fee schedule,51.38,100,,23.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.9,38,,167.808,percent of total billed charges,38% of total billed charges,51.38,100,,29.76,Fee Schedule,100% of LA custom fee schedule,770.94,2422,
Telemetry,3030001,CDM,279,RC,,,OUTPATIENT,,,290,174,,246.5,85,,197.2,Percent of total billed charges,85% of total billed charges,145,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,145,50,,640,percent of total billed charges,50% of total billed charges,92.66,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,92.66,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.2,38,,516.8,percent of total billed charges,38% of total billed charges,116,40,,127.04,percent of total billed charges,40% of total billed charges,771.94,2423,
ROOM/BED: Telemetry,3030001,CDM,279,RC,,,OUTPATIENT,,,1200,720,,1020,85,,816,Percent of total billed charges,85% of total billed charges,600,50,,640,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,600,50,,18.4,percent of total billed charges,50% of total billed charges,383.4,31.95,,126.264,percent of total billed charges,31.95% of total billed charges,383.4,31.95,,126.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,456,38,,179.36,percent of total billed charges,38% of total billed charges,480,40,,158.08,percent of total billed charges,40% of total billed charges,772.94,2424,
Bill Only Rh Phenotyping,3033248,CDM,302,RC,86906,HCPCS,OUTPATIENT,,,61,36.6,,51.85,85,,41.48,Percent of total billed charges,85% of total billed charges,36.14,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.14,136.6,,66.8,fee schedule,136.60% of BCBS custom fee schedule,8.53,110,,43.456,fee schedule,110% of LA custom fee schedule,7.75,100,,43.456,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,23.18,38,,45.6,percent of total billed charges,38% of total billed charges,7.75,100,,54.4,Fee Schedule,100% of LA custom fee schedule,773.94,2425,
UA Micro Standard,3038015,CDM,307,RC,81015,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,14.15,136.6,,66.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.15,136.6,,610,fee schedule,136.60% of BCBS custom fee schedule,3.36,110,,34.504,fee schedule,110% of LA custom fee schedule,3.05,100,,34.504,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.98,38,,256.88,percent of total billed charges,38% of total billed charges,3.05,100,,43.2,Fee Schedule,100% of LA custom fee schedule,774.94,2426,
ROOM/BED: ICU,3050001,CDM,200,RC,,,INPATIENT,,,1800,1080,,1300,100,,,per diem,pays based on per day rate,1762.2,50,,610,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1762.2,50,,3.6,percent of total billed charges,50% of total billed charges,,,,126.52,other,Not separately reimbursable,,31.95,,126.52,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2400,38,,717.136,percent of total billed charges,38% of total billed charges,,,,158.4,other,Not separately reimbursable,775.94,2427,
Antibody Screen Tube,3068509,CDM,302,RC,86850,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,31.76,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,31.76,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,7.41,110,,16.104,fee schedule,110% of LA custom fee schedule,6.74,100,,16.104,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.9,38,,256.576,percent of total billed charges,38% of total billed charges,6.74,100,,20.16,Fee Schedule,100% of LA custom fee schedule,776.94,2428,
RH Typing,3069010,CDM,302,RC,86901,HCPCS,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,15.89,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,15.89,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,3.29,110,,17.384,fee schedule,110% of LA custom fee schedule,2.99,100,,17.384,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.46,38,,334.4,percent of total billed charges,38% of total billed charges,2.99,100,,21.76,Fee Schedule,100% of LA custom fee schedule,777.94,2429,
AHG Crossmatch,3069226,CDM,302,RC,86922,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,20.71,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.71,136.6,,138.4,fee schedule,136.60% of BCBS custom fee schedule,53.83,110,,34.248,fee schedule,110% of LA custom fee schedule,48.94,100,,34.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.8,38,,912,percent of total billed charges,38% of total billed charges,48.94,100,,42.88,Fee Schedule,100% of LA custom fee schedule,778.94,2430,
AHG Crossmatch,3069226,CDM,302,RC,86922,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,20.71,136.6,,138.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.71,136.6,,23.672,fee schedule,136.60% of BCBS custom fee schedule,53.83,110,,65.432,fee schedule,110% of LA custom fee schedule,48.94,100,,65.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.8,38,,30.4,percent of total billed charges,38% of total billed charges,48.94,100,,81.92,Fee Schedule,100% of LA custom fee schedule,779.94,2431,
AHG Crossmatch BCE,3069226,CDM,302,RC,86922,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,20.71,136.6,,23.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.71,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,53.83,110,,16.36,fee schedule,110% of LA custom fee schedule,48.94,100,,16.36,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.8,38,,45.6,percent of total billed charges,38% of total billed charges,48.94,100,,20.48,Fee Schedule,100% of LA custom fee schedule,780.94,2432,
Compatible,3086774,CDM,302,RC,86923,HCPCS,OUTPATIENT,,,626,375.6,,532.1,85,,425.68,Percent of total billed charges,85% of total billed charges,29.92,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.92,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,200.01,31.95,,30.16,percent of total billed charges,31.95% of total billed charges,200.01,31.95,,30.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,237.88,38,,179.36,percent of total billed charges,38% of total billed charges,250.4,40,,37.76,percent of total billed charges,40% of total billed charges,781.94,2433,
Bill Only Antigen Testing,3086816,CDM,302,RC,86905,HCPCS,OUTPATIENT,,,800,480,,680,85,,544,Percent of total billed charges,85% of total billed charges,17.83,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.83,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,4.21,110,,21.216,fee schedule,110% of LA custom fee schedule,3.83,100,,21.216,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,304,38,,387.6,percent of total billed charges,38% of total billed charges,3.83,100,,26.56,Fee Schedule,100% of LA custom fee schedule,782.94,2434,
Bill ABID,3086873,CDM,302,RC,86870,HCPCS,OUTPATIENT,,,137,82.2,,116.45,85,,93.16,Percent of total billed charges,85% of total billed charges,54.91,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.91,136.6,,52.4,fee schedule,136.60% of BCBS custom fee schedule,48.25,110,,46.264,fee schedule,110% of LA custom fee schedule,43.86,100,,46.264,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,52.06,38,,456,percent of total billed charges,38% of total billed charges,43.86,100,,57.92,Fee Schedule,100% of LA custom fee schedule,783.94,2435,
Ref DAT,3086881,CDM,302,RC,86880,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,25.03,136.6,,52.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.03,136.6,,105.6,fee schedule,136.60% of BCBS custom fee schedule,5.93,110,,7.672,fee schedule,110% of LA custom fee schedule,5.39,100,,7.672,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.4,38,,387.6,percent of total billed charges,38% of total billed charges,5.39,100,,9.6,Fee Schedule,100% of LA custom fee schedule,784.94,2436,
INPATIENT HEMODIALYSIS,3120030,CDM,801,RC,,,OUTPATIENT,,,2500,1500,,2125,85,,1700,Percent of total billed charges,85% of total billed charges,1250,50,,105.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1250,50,,27.2,percent of total billed charges,50% of total billed charges,798.75,31.95,,164.504,percent of total billed charges,31.95% of total billed charges,798.75,31.95,,81.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,779.456,other,Not separately reimbursable,1000,40,,149.528,percent of total billed charges,40% of total billed charges,785.94,2437,
HEMODIALYSIS W/ PHYS/QHP EVAL,3120035,CDM,829,RC,90935,HCPCS,OUTPATIENT,,,1450,870,,1232.5,85,,986,Percent of total billed charges,85% of total billed charges,1851.42,136.6,,27.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1851.42,136.6,,111.2,fee schedule,136.60% of BCBS custom fee schedule,509.68,35.15,,107.864,fee schedule,35.15% of LA custom fee schedule,463.28,31.95,,107.864,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,200,100,,684,case rate,pays based on per visit rate,463.28,31.95,,135.04,Fee Schedule,31.95% of LA custom fee schedule,786.94,2438,
UNSCHED DIALYSIS ESRD PT HOSP,3120057,CDM,829,RC,G0257,HCPCS,OUTPATIENT,,,1450,870,,1232.5,85,,986,Percent of total billed charges,85% of total billed charges,1198.16,136.6,,111.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1198.16,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,509.68,35.15,,3.832,percent of total billed charges,35.15% of total billed charges,93.93,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,200,100,,1726.72,case rate,pays based on per visit rate,463.28,31.95,,4.8,percent of total billed charges,31.95% of total billed charges,787.94,2439,
HEMODIALYSIS W/ PHYS/QHP EVALUATION PROF,3120235,CDM,989,RC,90935,HCPCS,OUTPATIENT,,,245,147,,,,,,other,Not separately reimbursable,,,,8.4,other,Not separately reimbursable,98.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,2.8,other,Not separately reimbursable,,,,65.944,other,Not separately reimbursable,,31.95,,65.944,other,Not separately reimbursable,67.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,211.28,other,Not separately reimbursable,,,,82.56,other,Not separately reimbursable,788.94,2440,
UNSCHED DIALYSIS ESRD PT HOS PROF,3120257,CDM,989,RC,G0257,HCPCS,OUTPATIENT,,,245,147,,,,,,other,Not separately reimbursable,,,,2.8,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,,,,26.584,other,Not separately reimbursable,,31.95,,26.584,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,1493.856,other,Not separately reimbursable,,,,33.28,other,Not separately reimbursable,789.94,2441,
Exercise Stress Test,3473790,CDM,482,RC,93017,HCPCS,OUTPATIENT,,,977,586.2,,830.45,85,,664.36,Percent of total billed charges,85% of total billed charges,500.49,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,500.49,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,343.42,35.15,,6.392,fee schedule,35.15% of LA custom fee schedule,312.15,31.95,,6.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,371,100,,319.808,case rate,pays based on per visit rate,312.15,31.95,,8,Fee Schedule,31.95% of LA custom fee schedule,790.94,2442,
ABDOMINAL PARACENTESIS W/O IMAGING,3500001,CDM,450,RC,49082,HCPCS,OUTPATIENT,,,1941,1164.6,,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1621.77,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1621.77,136.6,,20.8,fee schedule,136.60% of BCBS custom fee schedule,682.26,35.15,,44.728,fee schedule,35.15% of LA custom fee schedule,620.15,31.95,,44.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,737.58,38,,881.6,percent of total billed charges,38% of total billed charges,620.15,31.95,,56,Fee Schedule,31.95% of LA custom fee schedule,791.94,2443,
ABDOMINAL PARACENTESIS WITH IMAGING,3500002,CDM,450,RC,49083,HCPCS,OUTPATIENT,,,1941,1164.6,,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1621.77,136.6,,20.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1621.77,136.6,,3.64,fee schedule,136.60% of BCBS custom fee schedule,682.26,35.15,,63.904,fee schedule,35.15% of LA custom fee schedule,620.15,31.95,,63.904,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,737.58,38,,179.36,percent of total billed charges,38% of total billed charges,620.15,31.95,,80,Fee Schedule,31.95% of LA custom fee schedule,792.94,2444,
ANOSCOPY DIAGNOSTIC W/WO COLLECTION,3500032,CDM,450,RC,46600,HCPCS,OUTPATIENT,,,1865,1119,,1585.25,85,,1268.2,Percent of total billed charges,85% of total billed charges,153.62,136.6,,3.64,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,595.87,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,595.87,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,708.7,38,,258.4,percent of total billed charges,38% of total billed charges,746,40,,89.6,percent of total billed charges,40% of total billed charges,793.94,2445,
RMVL FB MUSCLE/TENDON SHEATH DEEP/COMP,3500036,CDM,450,RC,20525,HCPCS,OUTPATIENT,,,6500,3900,,5525,85,,4420,Percent of total billed charges,85% of total billed charges,4899.65,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4899.65,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,2076.75,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,2076.75,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2470,38,,119.472,percent of total billed charges,38% of total billed charges,2600,40,,48,percent of total billed charges,40% of total billed charges,794.94,2446,
"ARTHROCENTESIS, ASPIRATION AND /OR INJECTION, INTERMEDIATE J",3500040,CDM,450,RC,20605,HCPCS,OUTPATIENT,,,552,331.2,,469.2,85,,375.36,Percent of total billed charges,85% of total billed charges,567.44,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,194.03,35.15,,62.88,fee schedule,35.15% of LA custom fee schedule,176.36,31.95,,62.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,209.76,38,,194.256,percent of total billed charges,38% of total billed charges,176.36,31.95,,78.72,Fee Schedule,31.95% of LA custom fee schedule,795.94,2447,
"ARTHROCENTESIS, ASPIRATION AND /OR INJECTION, MAJOR JOINT OR BURSA (SHOULDER, HI",3500041,CDM,450,RC,20610,HCPCS,OUTPATIENT,,,552,331.2,,469.2,85,,375.36,Percent of total billed charges,85% of total billed charges,567.44,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,194.03,35.15,,55.208,fee schedule,35.15% of LA custom fee schedule,176.36,31.95,,55.208,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,209.76,38,,194.256,percent of total billed charges,38% of total billed charges,176.36,31.95,,69.12,Fee Schedule,31.95% of LA custom fee schedule,796.94,2448,
ASPIRATION BLADDER W SUP CATH 51102,3500042,CDM,450,RC,51102,HCPCS,OUTPATIENT,,,1700,1020,,1445,85,,1156,Percent of total billed charges,85% of total billed charges,5182.33,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5182.33,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,113.744,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,113.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,646,38,,817.456,percent of total billed charges,38% of total billed charges,543.15,31.95,,142.4,Fee Schedule,31.95% of LA custom fee schedule,797.94,2449,
"AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE",3500044,CDM,450,RC,11730,HCPCS,OUTPATIENT,,,590,354,,501.5,85,,401.2,Percent of total billed charges,85% of total billed charges,265.43,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,207.39,35.15,,34.248,fee schedule,35.15% of LA custom fee schedule,188.51,31.95,,34.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,224.2,38,,1012.32,percent of total billed charges,38% of total billed charges,188.51,31.95,,42.88,Fee Schedule,31.95% of LA custom fee schedule,798.94,2450,
AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL,3500047,CDM,450,RC,11732,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,212.22,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,70.8,fee schedule,35.15% of LA custom fee schedule,47.93,31.95,,70.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,194.256,percent of total billed charges,38% of total billed charges,47.93,31.95,,88.64,Fee Schedule,31.95% of LA custom fee schedule,799.94,2451,
BLADDER IRRIGATION LAVAGE/INSTILLAT,3500070,CDM,450,RC,51700,HCPCS,OUTPATIENT,,,845,507,,718.25,85,,574.6,Percent of total billed charges,85% of total billed charges,290.38,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,290.38,136.6,,41.6,fee schedule,136.60% of BCBS custom fee schedule,297.02,35.15,,22.24,fee schedule,35.15% of LA custom fee schedule,269.98,31.95,,22.24,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,321.1,38,,664.24,percent of total billed charges,38% of total billed charges,269.98,31.95,,27.84,Fee Schedule,31.95% of LA custom fee schedule,800.94,2452,
CENTRAL VENOUS CATHETER NON-TUNNELED  AGE < 5 Y,3500076,CDM,450,RC,36555,HCPCS,OUTPATIENT,,,2359,1415.4,,2005.15,85,,1604.12,Percent of total billed charges,85% of total billed charges,2060.64,136.6,,41.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2060.64,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,753.7,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,753.7,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,896.42,38,,230.432,percent of total billed charges,38% of total billed charges,943.6,40,,22.4,percent of total billed charges,40% of total billed charges,801.94,2453,
CHANGE CYSTOSTOMY TUBE SIMP 51705,3500083,CDM,450,RC,51705,HCPCS,OUTPATIENT,,,844,506.4,,717.4,85,,573.92,Percent of total billed charges,85% of total billed charges,560.11,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,560.11,136.6,,404,fee schedule,136.60% of BCBS custom fee schedule,269.66,31.95,,124.48,percent of total billed charges,31.95% of total billed charges,269.66,31.95,,124.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,320.72,38,,1393.84,percent of total billed charges,38% of total billed charges,337.6,40,,155.84,percent of total billed charges,40% of total billed charges,802.94,2454,
43762 REPLACEMENT GASTROSTOMY TUBE,3500084,CDM,360,RC,43762,HCPCS,OUTPATIENT,,,925,555,,786.25,85,,629,Percent of total billed charges,85% of total billed charges,973.51,136.6,,404,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,973.51,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,295.54,31.95,,48.568,percent of total billed charges,31.95% of total billed charges,295.54,31.95,,48.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,334.4,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,370,40,,60.8,percent of total billed charges,40% of total billed charges,803.94,2455,
43763 REPLACEMENT GASTROSTOMY TUBE,3500089,CDM,360,RC,43763,HCPCS,OUTPATIENT,,,1230,738,,1045.5,85,,836.4,Percent of total billed charges,85% of total billed charges,973.51,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,973.51,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,392.99,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,392.99,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,119.472,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,492,40,,67.2,percent of total billed charges,40% of total billed charges,804.94,2456,
"DEBRIDEMENT SKIN, SUBCUTANEOUS TISSUE",3500146,CDM,450,RC,11042,HCPCS,OUTPATIENT,,,1100,660,,935,85,,748,Percent of total billed charges,85% of total billed charges,1307.44,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1307.44,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,351.45,31.95,,236.688,percent of total billed charges,31.95% of total billed charges,351.45,31.95,,236.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,418,38,,256.576,percent of total billed charges,38% of total billed charges,440,40,,296.32,percent of total billed charges,40% of total billed charges,805.94,2457,
SUTURE OR STAPLE RMVL W/ ANES,3500151,CDM,450,RC,15851,HCPCS,OUTPATIENT,,,3000,1800,,2550,85,,2040,Percent of total billed charges,85% of total billed charges,627.84,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,627.84,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,1054.5,35.15,,29.392,percent of total billed charges,35.15% of total billed charges,93.93,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1140,38,,119.472,percent of total billed charges,38% of total billed charges,958.5,31.95,,36.8,percent of total billed charges,31.95% of total billed charges,806.94,2458,
SUTURE OR STAPLE RMVL W/O ANES,3500153,CDM,450,RC,15853,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,0.01,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,75.6,fee schedule,136.60% of BCBS custom fee schedule,35.15,35.15,,6.392,fee schedule,35.15% of LA custom fee schedule,31.95,31.95,,6.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,38,38,,183.008,percent of total billed charges,38% of total billed charges,31.95,31.95,,8,Fee Schedule,31.95% of LA custom fee schedule,807.94,2459,
SUTURE AND STAPLE RMVL W/O ANES,3500154,CDM,450,RC,15854,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,0.01,136.6,,75.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,6.392,fee schedule,35.15% of LA custom fee schedule,47.93,31.95,,6.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,182.4,percent of total billed charges,38% of total billed charges,47.93,31.95,,8,Fee Schedule,31.95% of LA custom fee schedule,808.94,2460,
"DRESSING AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; L",3500163,CDM,450,RC,16030,HCPCS,OUTPATIENT,,,590,354,,501.5,85,,401.2,Percent of total billed charges,85% of total billed charges,295,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,295,50,,6.4,percent of total billed charges,50% of total billed charges,188.51,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,188.51,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,224.2,38,,430.464,percent of total billed charges,38% of total billed charges,236,40,,12.8,percent of total billed charges,40% of total billed charges,809.94,2461,
Impedance,3500177,CDM,750,RC,91037,HCPCS,OUTPATIENT,,,422,253.2,,358.7,85,,286.96,Percent of total billed charges,85% of total billed charges,718.94,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,718.94,136.6,,358,fee schedule,136.60% of BCBS custom fee schedule,148.33,35.15,,12.784,fee schedule,35.15% of LA custom fee schedule,134.83,31.95,,12.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,110.96,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,134.83,31.95,,16,Fee Schedule,31.95% of LA custom fee schedule,810.94,2462,
Esophageal Manometry,3500178,CDM,750,RC,91010,HCPCS,OUTPATIENT,,,930,558,,790.5,85,,632.4,Percent of total billed charges,85% of total billed charges,718.94,136.6,,358,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,718.94,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,326.9,35.15,,12.784,fee schedule,35.15% of LA custom fee schedule,297.14,31.95,,12.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,1064,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,297.14,31.95,,16,Fee Schedule,31.95% of LA custom fee schedule,811.94,2463,
"EXCISION BENIGN LESION 0.6-1.0 CM, TRUNK, ARMS, LEGS",3500182,CDM,450,RC,11401,HCPCS,OUTPATIENT,,,1275,765,,1083.75,85,,867,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,407.36,31.95,,118.856,percent of total billed charges,31.95% of total billed charges,407.36,31.95,,118.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,484.5,38,,79.04,percent of total billed charges,38% of total billed charges,510,40,,148.8,percent of total billed charges,40% of total billed charges,812.94,2464,
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2.0 CM,3500183,CDM,450,RC,11402,HCPCS,OUTPATIENT,,,1500,900,,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,570,38,,106.4,percent of total billed charges,38% of total billed charges,600,40,,160,percent of total billed charges,40% of total billed charges,813.94,2465,
"EXCISION BENIGN LESION FACE, EARS, EYELIDS  LESION DIAMETER 0.5CM OR LESS",3500186,CDM,450,RC,11440,HCPCS,OUTPATIENT,,,1275,765,,1083.75,85,,867,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,407.36,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,407.36,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,484.5,38,,779.456,percent of total billed charges,38% of total billed charges,510,40,,160,percent of total billed charges,40% of total billed charges,814.94,2466,
"EXCISION BENIGN LESION FACE, EARS, EYELIDS LESION DIAMETER 1.1-2.0 CM",3500188,CDM,450,RC,11442,HCPCS,OUTPATIENT,,,2564,1538.4,,2179.4,85,,1743.52,Percent of total billed charges,85% of total billed charges,1737.65,136.6,,142.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.65,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,819.2,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,819.2,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,974.32,38,,101.84,percent of total billed charges,38% of total billed charges,1025.6,40,,160,percent of total billed charges,40% of total billed charges,815.94,2467,
RDCT PROCIDENTIA UNDER ANES SEP PROC,3500195,CDM,450,RC,45900,HCPCS,OUTPATIENT,,,2250,1350,,1912.5,85,,1530,Percent of total billed charges,85% of total billed charges,877.38,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,877.38,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,718.88,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,718.88,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,855,38,,594.32,percent of total billed charges,38% of total billed charges,900,40,,160,percent of total billed charges,40% of total billed charges,816.94,2468,
EXCISION EXTERNAL HEMORRHOID TAG,3500200,CDM,450,RC,46230,HCPCS,OUTPATIENT,,,5680,3408,,4828,85,,3862.4,Percent of total billed charges,85% of total billed charges,4528.15,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4528.15,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,1814.76,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,1814.76,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2158.4,38,,497.952,percent of total billed charges,38% of total billed charges,2272,40,,160,percent of total billed charges,40% of total billed charges,817.94,2469,
INCISION THROMBOSED HEMORRHOID EXTERNAL,3500222,CDM,450,RC,46083,HCPCS,OUTPATIENT,,,695,417,,590.75,85,,472.6,Percent of total billed charges,85% of total billed charges,877.38,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,877.38,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,222.05,31.95,,203.968,percent of total billed charges,31.95% of total billed charges,222.05,31.95,,203.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,264.1,38,,71.136,percent of total billed charges,38% of total billed charges,278,40,,255.36,percent of total billed charges,40% of total billed charges,818.94,2470,
EXCISION OF LESION OF TENDON SHEALTH OR JOINT CAPSULE (MUCOUS CYST OR GANGLION);,3500224,CDM,450,RC,26160,HCPCS,OUTPATIENT,,,4914,2948.4,,4176.9,85,,3341.52,Percent of total billed charges,85% of total billed charges,3915.28,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3915.28,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,1570.02,31.95,,823.8,percent of total billed charges,31.95% of total billed charges,1570.02,31.95,,823.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1867.32,38,,51.072,percent of total billed charges,38% of total billed charges,1965.6,40,,1031.36,percent of total billed charges,40% of total billed charges,819.94,2471,
"EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE",3500226,CDM,450,RC,11750,HCPCS,OUTPATIENT,,,1052,631.2,,894.2,85,,715.36,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,336.11,31.95,,330.232,percent of total billed charges,31.95% of total billed charges,336.11,31.95,,330.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,399.76,38,,91.2,percent of total billed charges,38% of total billed charges,420.8,40,,413.44,percent of total billed charges,40% of total billed charges,820.94,2472,
"EXCISION THROMBOSED HEMORRHOID,EXT",3500235,CDM,450,RC,46320,HCPCS,OUTPATIENT,,,2900,1740,,2465,85,,1972,Percent of total billed charges,85% of total billed charges,877.38,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,877.38,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,926.55,31.95,,243.072,percent of total billed charges,31.95% of total billed charges,926.55,31.95,,243.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1102,38,,70.224,percent of total billed charges,38% of total billed charges,1160,40,,304.32,percent of total billed charges,40% of total billed charges,821.94,2473,
FINE NEEDLE ASPIRATION WITHOUT IMAGING GUIDANCE,3500269,CDM,450,RC,10021,HCPCS,OUTPATIENT,,,590,354,,501.5,85,,401.2,Percent of total billed charges,85% of total billed charges,1230.96,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1230.96,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,207.39,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,188.51,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,224.2,38,,179.36,percent of total billed charges,38% of total billed charges,188.51,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,822.94,2474,
NASO/ORO-GASTRIC TUBE PLCMT W/FLUORO,3500280,CDM,450,RC,43752,HCPCS,OUTPATIENT,,,850,510,,722.5,85,,578,Percent of total billed charges,85% of total billed charges,332.74,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,332.74,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,298.78,35.15,,255.6,fee schedule,35.15% of LA custom fee schedule,271.58,31.95,,255.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,323,38,,88.16,percent of total billed charges,38% of total billed charges,271.58,31.95,,320,Fee Schedule,31.95% of LA custom fee schedule,823.94,2475,
GASTRIC INTUBATION/ASP THERAPEUTIC,3500281,CDM,450,RC,43753,HCPCS,OUTPATIENT,,,393,235.8,,334.05,85,,267.24,Percent of total billed charges,85% of total billed charges,194.46,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.46,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,138.14,35.15,,165.12,fee schedule,35.15% of LA custom fee schedule,125.56,31.95,,165.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,149.34,38,,69.312,percent of total billed charges,38% of total billed charges,125.56,31.95,,206.72,Fee Schedule,31.95% of LA custom fee schedule,824.94,2476,
INCISION AND DRAINAGE OF ABSCESS CARBUNCLE SUPPURATIVE HIDRADENITIS CUTANEOUS OR,3500315,CDM,450,RC,10061,HCPCS,OUTPATIENT,,,639,383.4,,543.15,85,,434.52,Percent of total billed charges,85% of total billed charges,960.27,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,960.27,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,204.16,31.95,,193.488,percent of total billed charges,31.95% of total billed charges,204.16,31.95,,193.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,242.82,38,,35.264,percent of total billed charges,38% of total billed charges,255.6,40,,242.24,percent of total billed charges,40% of total billed charges,825.94,2477,
"INCISION AND DRAINAGE OF ABSCESS (CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS",3500316,CDM,450,RC,10060,HCPCS,OUTPATIENT,,,639,383.4,,543.15,85,,434.52,Percent of total billed charges,85% of total billed charges,495.68,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,204.16,31.95,,367.04,percent of total billed charges,31.95% of total billed charges,204.16,31.95,,367.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,242.82,38,,101.84,percent of total billed charges,38% of total billed charges,255.6,40,,459.52,percent of total billed charges,40% of total billed charges,826.94,2478,
INCISION  DRAINAGE OF HEMATOMA SEROMA OR FLUID COLLECTION,3500317,CDM,450,RC,10140,HCPCS,OUTPATIENT,,,2689,1613.4,,2285.65,85,,1828.52,Percent of total billed charges,85% of total billed charges,3962.6,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3962.6,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,859.14,31.95,,205.504,percent of total billed charges,31.95% of total billed charges,859.14,31.95,,205.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1021.82,38,,51.68,percent of total billed charges,38% of total billed charges,1075.6,40,,257.28,percent of total billed charges,40% of total billed charges,827.94,2479,
INCISION AND DRAINAGE PERIANAL ABSCESS SUPERFICIAL,3500318,CDM,450,RC,46050,HCPCS,OUTPATIENT,,,3330,1998,,2830.5,85,,2264.4,Percent of total billed charges,85% of total billed charges,877.38,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,877.38,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,1063.94,31.95,,206.016,percent of total billed charges,31.95% of total billed charges,1063.94,31.95,,206.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1265.4,38,,144.4,percent of total billed charges,38% of total billed charges,1332,40,,257.92,percent of total billed charges,40% of total billed charges,828.94,2480,
INCISION AND DRAINAGE PILONDIAL CYST/SIMPLE,3500320,CDM,450,RC,10080,HCPCS,OUTPATIENT,,,639,383.4,,543.15,85,,434.52,Percent of total billed charges,85% of total billed charges,2437.09,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2437.09,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,204.16,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,204.16,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,242.82,38,,51.072,percent of total billed charges,38% of total billed charges,255.6,40,,160,percent of total billed charges,40% of total billed charges,829.94,2481,
INCISION AND DRAINAGE PILONIDAL CYST COMPLICATED,3500321,CDM,450,RC,10081,HCPCS,OUTPATIENT,,,2185,1311,,1857.25,85,,1485.8,Percent of total billed charges,85% of total billed charges,1092.5,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1092.5,50,,31.2,percent of total billed charges,50% of total billed charges,698.11,31.95,,996.072,percent of total billed charges,31.95% of total billed charges,698.11,31.95,,996.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,830.3,38,,51.072,percent of total billed charges,38% of total billed charges,874,40,,1247.04,percent of total billed charges,40% of total billed charges,830.94,2482,
INCISION AND DRAINAGE VULVA/PERINEAL ABSCESS,3500322,CDM,450,RC,56405,HCPCS,OUTPATIENT,,,758,454.8,,644.3,85,,515.44,Percent of total billed charges,85% of total billed charges,595.96,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,242.18,31.95,,235.408,percent of total billed charges,31.95% of total billed charges,242.18,31.95,,235.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,288.04,38,,106.4,percent of total billed charges,38% of total billed charges,303.2,40,,294.72,percent of total billed charges,40% of total billed charges,831.94,2483,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; COMPLICATED",3500325,CDM,450,RC,10121,HCPCS,OUTPATIENT,,,4585,2751,,3897.25,85,,3117.8,Percent of total billed charges,85% of total billed charges,5786.29,136.6,,31.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5786.29,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,1464.91,31.95,,282.696,percent of total billed charges,31.95% of total billed charges,1464.91,31.95,,282.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1742.3,38,,51.072,percent of total billed charges,38% of total billed charges,1834,40,,353.92,percent of total billed charges,40% of total billed charges,832.94,2484,
"INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; SIMPLE",3500326,CDM,450,RC,10120,HCPCS,OUTPATIENT,,,1100,660,,935,85,,748,Percent of total billed charges,85% of total billed charges,948.82,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,351.45,31.95,,765.776,percent of total billed charges,31.95% of total billed charges,351.45,31.95,,765.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,418,38,,83.904,percent of total billed charges,38% of total billed charges,440,40,,958.72,percent of total billed charges,40% of total billed charges,833.94,2485,
"96402 CHEMO ADMIN, SUBCUT OR IM, HORMONAL CHARGE",3500329,CDM,260,RC,96402,HCPCS,OUTPATIENT,,,87,52.2,,73.95,85,,59.16,Percent of total billed charges,85% of total billed charges,231.55,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,231.55,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,30.58,35.15,,74.376,fee schedule,35.15% of LA custom fee schedule,27.8,31.95,,74.376,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,121.296,case rate,pays based on per visit rate,27.8,31.95,,93.12,Fee Schedule,31.95% of LA custom fee schedule,834.94,2486,
INSERT NON INDWELL BLAD CATH,3500338,CDM,450,RC,51701,HCPCS,OUTPATIENT,,,393,235.8,,334.05,85,,267.24,Percent of total billed charges,85% of total billed charges,153.63,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.63,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,138.14,35.15,,111.696,fee schedule,35.15% of LA custom fee schedule,125.56,31.95,,111.696,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,149.34,38,,242.288,percent of total billed charges,38% of total billed charges,125.56,31.95,,139.84,Fee Schedule,31.95% of LA custom fee schedule,835.94,2487,
INSERTION TEMPORARY BLADDDER CATHETER COMPLEX,3500343,CDM,450,RC,51703,HCPCS,OUTPATIENT,,,844,506.4,,717.4,85,,573.92,Percent of total billed charges,85% of total billed charges,290.38,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,290.38,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,269.66,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,269.66,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,320.72,38,,590.064,percent of total billed charges,38% of total billed charges,337.6,40,,160,percent of total billed charges,40% of total billed charges,836.94,2488,
INSERTION TEMPORARY INDWELLING BLADDER CATHETER SIMPLE,3500344,CDM,450,RC,51702,HCPCS,OUTPATIENT,,,393,235.8,,334.05,85,,267.24,Percent of total billed charges,85% of total billed charges,153.63,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.63,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,138.14,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,125.56,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,149.34,38,,590.064,percent of total billed charges,38% of total billed charges,125.56,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,837.94,2489,
LARYNGOSCOPY INDIRECT DIAGNOSTIC,3500363,CDM,450,RC,31505,HCPCS,OUTPATIENT,,,602,361.2,,511.7,85,,409.36,Percent of total billed charges,85% of total billed charges,201.12,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,201.12,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,211.6,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,192.34,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,228.76,38,,497.952,percent of total billed charges,38% of total billed charges,192.34,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,838.94,2490,
LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,3500367,CDM,450,RC,31575,HCPCS,OUTPATIENT,,,600,360,,510,85,,408,Percent of total billed charges,85% of total billed charges,361.69,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,361.69,136.6,,24.336,fee schedule,136.60% of BCBS custom fee schedule,191.7,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,191.7,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,22.8,percent of total billed charges,38% of total billed charges,240,40,,160,percent of total billed charges,40% of total billed charges,839.94,2491,
LUMBAR PUNCTURE,3500371,CDM,450,RC,62270,HCPCS,OUTPATIENT,,,1416,849.6,,1203.6,85,,962.88,Percent of total billed charges,85% of total billed charges,567.44,136.6,,24.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,33.6,fee schedule,136.60% of BCBS custom fee schedule,452.41,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,452.41,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,538.08,38,,299.44,percent of total billed charges,38% of total billed charges,566.4,40,,160,percent of total billed charges,40% of total billed charges,840.94,2492,
MARSUPIALIZATION BARTHOLINS CYST,3500375,CDM,450,RC,56420,HCPCS,OUTPATIENT,,,365,219,,310.25,85,,248.2,Percent of total billed charges,85% of total billed charges,595.96,136.6,,33.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,116.62,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,116.62,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,138.7,38,,63.84,percent of total billed charges,38% of total billed charges,146,40,,160,percent of total billed charges,40% of total billed charges,841.94,2493,
ANTEPARTUM CARE ONLY 7+ VISITS,3500376,CDM,450,RC,59426,HCPCS,OUTPATIENT,,,3500,2100,,2975,85,,2380,Percent of total billed charges,85% of total billed charges,1750,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1750,50,,47.2,percent of total billed charges,50% of total billed charges,1230.25,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,94.89,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1330,38,,1664.4,percent of total billed charges,38% of total billed charges,1118.25,31.95,,160,percent of total billed charges,31.95% of total billed charges,842.94,2494,
CANALITH REPOSITIONING PROCEDURE,3500380,CDM,450,RC,95992,HCPCS,OUTPATIENT,,,260,156,,221,85,,176.8,Percent of total billed charges,85% of total billed charges,130,50,,47.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,130,50,,9.04,percent of total billed charges,50% of total billed charges,91.39,35.15,,371.896,fee schedule,35.15% of LA custom fee schedule,83.07,31.95,,371.896,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,98.8,38,,197.6,percent of total billed charges,38% of total billed charges,83.07,31.95,,465.6,Fee Schedule,31.95% of LA custom fee schedule,843.94,2495,
NEG PRESS WOUND TX < 50 CM,3500383,CDM,450,RC,97605,HCPCS,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,212.22,136.6,,9.04,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,1.904,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,575.608,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,575.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,186.96,percent of total billed charges,38% of total billed charges,111.83,31.95,,720.64,percent of total billed charges,31.95% of total billed charges,844.94,2496,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; SIMPLE,3500419,CDM,450,RC,20520,HCPCS,OUTPATIENT,,,2564,1538.4,,2179.4,85,,1743.52,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,1.904,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,819.2,31.95,,223.136,percent of total billed charges,31.95% of total billed charges,819.2,31.95,,223.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,974.32,38,,1121.76,percent of total billed charges,38% of total billed charges,1025.6,40,,279.36,percent of total billed charges,40% of total billed charges,845.94,2497,
"REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA, UPT TO AND INCLUDI",3500420,CDM,450,RC,11200,HCPCS,OUTPATIENT,,,335,201,,284.75,85,,227.8,Percent of total billed charges,85% of total billed charges,265.43,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,117.75,35.15,,85.624,fee schedule,35.15% of LA custom fee schedule,107.03,31.95,,85.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,127.3,38,,1121.76,percent of total billed charges,38% of total billed charges,107.03,31.95,,107.2,Fee Schedule,31.95% of LA custom fee schedule,846.94,2498,
REMOVAL TUNNEL CVC W/O 36589,3500422,CDM,450,RC,36589,HCPCS,OUTPATIENT,,,1955,1173,,1661.75,85,,1329.4,Percent of total billed charges,85% of total billed charges,2060.64,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2060.64,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,624.62,31.95,,75.912,percent of total billed charges,31.95% of total billed charges,624.62,31.95,,75.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,742.9,38,,97.28,percent of total billed charges,38% of total billed charges,782,40,,95.04,percent of total billed charges,40% of total billed charges,847.94,2499,
"REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM",3500441,CDM,450,RC,13101,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,5.2,percent of total billed charges,50% of total billed charges,523.34,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,27.36,percent of total billed charges,38% of total billed charges,655.2,40,,160,percent of total billed charges,40% of total billed charges,848.94,2500,
REPLACE TRACH TUBE 31502,3500442,CDM,450,RC,31502,HCPCS,OUTPATIENT,,,234,140.4,,198.9,85,,159.12,Percent of total billed charges,85% of total billed charges,560.11,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,560.11,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,74.76,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,74.76,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.92,38,,288.8,percent of total billed charges,38% of total billed charges,93.6,40,,160,percent of total billed charges,40% of total billed charges,849.94,2501,
"Shave (Epi)Dermal Lesion, Single, Face/Ears/Eyelids/Nose/Lips/Mucous Membrane; D",3500450,CDM,521,RC,11310,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,265.43,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,30.4,percent of total billed charges,38% of total billed charges,67.2,40,,160,percent of total billed charges,40% of total billed charges,850.94,2502,
"SHAVE SKIN LESION 0.5 CM FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE",3500450,CDM,450,RC,11310,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,265.43,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,8.848,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,95.85,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,114,38,,103.36,percent of total billed charges,38% of total billed charges,95.85,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,851.94,2503,
"Shave (Epi)Dermal Lesion, Single, Face/Ears/Eyelids/Nose/Lips/Mucous Memb; Diam",3500451,CDM,521,RC,11312,HCPCS,OUTPATIENT,,,231,138.6,,196.35,85,,157.08,Percent of total billed charges,85% of total billed charges,265.43,136.6,,8.848,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,11.48,fee schedule,136.60% of BCBS custom fee schedule,73.8,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,73.8,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,87.78,38,,212.8,percent of total billed charges,38% of total billed charges,92.4,40,,160,percent of total billed charges,40% of total billed charges,852.94,2504,
"Shave (Epi)Dermal Lesion, Single, Face/Ears/Eyelids/Nose/Lips/Mucous Membrane; D",3500452,CDM,521,RC,11313,HCPCS,OUTPATIENT,,,590,354,,501.5,85,,401.2,Percent of total billed charges,85% of total billed charges,627.84,136.6,,11.48,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,627.84,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,188.51,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,188.51,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,224.2,38,,21.28,percent of total billed charges,38% of total billed charges,236,40,,160,percent of total billed charges,40% of total billed charges,853.94,2505,
"Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 1.1 to",3500453,CDM,521,RC,11307,HCPCS,OUTPATIENT,,,290,174,,246.5,85,,197.2,Percent of total billed charges,85% of total billed charges,265.43,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,92.66,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,92.66,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,110.2,38,,28.88,percent of total billed charges,38% of total billed charges,116,40,,160,percent of total billed charges,40% of total billed charges,854.94,2506,
"Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 2.0+ c",3500454,CDM,521,RC,11308,HCPCS,OUTPATIENT,,,228,136.8,,193.8,85,,155.04,Percent of total billed charges,85% of total billed charges,265.43,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,26.8,fee schedule,136.60% of BCBS custom fee schedule,72.85,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,72.85,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,86.64,38,,38,percent of total billed charges,38% of total billed charges,91.2,40,,160,percent of total billed charges,40% of total billed charges,855.94,2507,
"Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.5 cm",3500455,CDM,521,RC,11305,HCPCS,OUTPATIENT,,,116,69.6,,98.6,85,,78.88,Percent of total billed charges,85% of total billed charges,265.43,136.6,,26.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,2.384,fee schedule,136.60% of BCBS custom fee schedule,37.06,31.95,,30.368,percent of total billed charges,31.95% of total billed charges,37.06,31.95,,81.28,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,44.08,38,,45.6,percent of total billed charges,38% of total billed charges,46.4,40,,27.608,percent of total billed charges,40% of total billed charges,856.94,2508,
"Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam",3500456,CDM,521,RC,11301,HCPCS,OUTPATIENT,,,335,201,,284.75,85,,227.8,Percent of total billed charges,85% of total billed charges,212.22,136.6,,2.384,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,107.03,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,107.03,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,127.3,38,,153.52,percent of total billed charges,38% of total billed charges,134,40,,9.6,percent of total billed charges,40% of total billed charges,857.94,2509,
"Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 1.1 to 2.0 cm Charge",3500457,CDM,521,RC,11302,HCPCS,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,265.43,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,54.32,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,64.6,38,,22.8,percent of total billed charges,38% of total billed charges,68,40,,16,percent of total billed charges,40% of total billed charges,858.94,2510,
"Shaving of lesion, single lesion, trunk, arms or legs; >2.0 cm  Technical Charge",3500458,CDM,521,RC,11303,HCPCS,OUTPATIENT,,,475,285,,403.75,85,,323,Percent of total billed charges,85% of total billed charges,409.01,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,409.01,136.6,,30.4,fee schedule,136.60% of BCBS custom fee schedule,151.76,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,151.76,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,180.5,38,,152.416,percent of total billed charges,38% of total billed charges,190,40,,34.56,percent of total billed charges,40% of total billed charges,859.94,2511,
"Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 0.5 cm > Charge",3500459,CDM,521,RC,11300,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,212.22,136.6,,30.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,26.96,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,86.048,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,81.28,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,57.152,percent of total billed charges,38% of total billed charges,67.2,40,,78.216,percent of total billed charges,40% of total billed charges,860.94,2512,
"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 12.6 cm",3500465,CDM,521,RC,12005,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,84,50,,26.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84,50,,6.272,percent of total billed charges,50% of total billed charges,53.68,31.95,,21.088,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,81.28,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,699.2,percent of total billed charges,38% of total billed charges,67.2,40,,19.168,percent of total billed charges,40% of total billed charges,861.94,2513,
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK AXILLAE EXTERNAL GENITALIA TRU,3500465,CDM,450,RC,12005,HCPCS,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,175,50,,6.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,175,50,,91.672,percent of total billed charges,50% of total billed charges,111.83,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,111.83,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,355.68,percent of total billed charges,38% of total billed charges,140,40,,187.2,percent of total billed charges,40% of total billed charges,862.94,2514,
"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 2.6 cm t",3500466,CDM,450,RC,12002,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,495.68,136.6,,91.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,5.184,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,231.576,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,231.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.84,38,,22.8,percent of total billed charges,38% of total billed charges,67.2,40,,289.92,percent of total billed charges,40% of total billed charges,863.94,2515,
SIM REP OF SUPR WNDS OF SCP NECK AXI EXT GENI TRNK A/O EXTR (INCL HANDS  FEET),3500466,CDM,450,RC,12002,HCPCS,OUTPATIENT,,,276,165.6,,234.6,85,,187.68,Percent of total billed charges,85% of total billed charges,495.68,136.6,,5.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,88.18,31.95,,631.84,percent of total billed charges,31.95% of total billed charges,88.18,31.95,,631.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.88,38,,22.8,percent of total billed charges,38% of total billed charges,110.4,40,,791.04,percent of total billed charges,40% of total billed charges,864.94,2516,
"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 20.1 cm",3500467,CDM,450,RC,12006,HCPCS,OUTPATIENT,,,399,239.4,,339.15,85,,271.32,Percent of total billed charges,85% of total billed charges,199.5,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,199.5,50,,68.44,percent of total billed charges,50% of total billed charges,127.48,31.95,,86.048,percent of total billed charges,31.95% of total billed charges,127.48,31.95,,81.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,151.62,38,,22.8,percent of total billed charges,38% of total billed charges,159.6,40,,78.216,percent of total billed charges,40% of total billed charges,865.94,2517,
SIMPLE REPAIR OF SUPERFICIAL WOUND OF SCALP NECK AXILLAE EXTERNAL GENITALIA TRUN,3500467,CDM,450,RC,12006,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,398.5,50,,68.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398.5,50,,9.6,percent of total billed charges,50% of total billed charges,254.64,31.95,,78.216,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,78.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,22.8,percent of total billed charges,38% of total billed charges,318.8,40,,97.92,percent of total billed charges,40% of total billed charges,866.94,2518,
THORACENTESIS FOR ASP,3500480,CDM,402,RC,32555,HCPCS,OUTPATIENT,,,1941,1164.6,,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1734.79,136.6,,9.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1734.79,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,620.15,31.95,,631.84,percent of total billed charges,31.95% of total billed charges,620.15,31.95,,631.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,265,100,,182.4,case rate,pays based on per visit rate,776.4,40,,791.04,percent of total billed charges,40% of total billed charges,867.94,2519,
THORACENTESIS NED/ASP/WO,3500481,CDM,450,RC,32554,HCPCS,OUTPATIENT,,,1941,1164.6,,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1734.79,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1734.79,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,620.15,31.95,,5.064,percent of total billed charges,31.95% of total billed charges,620.15,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,737.58,38,,182.4,percent of total billed charges,38% of total billed charges,776.4,40,,4.6,percent of total billed charges,40% of total billed charges,868.94,2520,
THORACOSTOMY TUBE,3500482,CDM,450,RC,32551,HCPCS,OUTPATIENT,,,1941,1164.6,,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1393.91,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1393.91,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,682.26,35.15,,86.048,fee schedule,35.15% of LA custom fee schedule,620.15,31.95,,81.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,737.58,38,,22.8,percent of total billed charges,38% of total billed charges,620.15,31.95,,78.216,Fee Schedule,31.95% of LA custom fee schedule,869.94,2521,
TX SUPERFICIAL WOUND DEHISCENCE W/PACKING,3500489,CDM,975,RC,12021,HCPCS,OUTPATIENT,,,650,390,,,,,,other,Not separately reimbursable,,,,7.2,other,Not separately reimbursable,182.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,18.632,other,Not separately reimbursable,,,,42.944,other,Not separately reimbursable,,31.95,,42.944,other,Not separately reimbursable,132.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,107.008,other,Not separately reimbursable,,,,53.76,other,Not separately reimbursable,870.94,2522,
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE,3500490,CDM,450,RC,12020,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,18.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,22.176,percent of total billed charges,50% of total billed charges,523.34,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,418.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,107.008,percent of total billed charges,38% of total billed charges,655.2,40,,524.16,percent of total billed charges,40% of total billed charges,871.94,2523,
ENDOTRACHEAL INTUBATION ED,3500508,CDM,410,RC,31500,HCPCS,OUTPATIENT,,,639,383.4,,543.15,85,,434.52,Percent of total billed charges,85% of total billed charges,615.38,136.6,,22.176,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,615.38,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,224.61,35.15,,98.424,fee schedule,35.15% of LA custom fee schedule,204.16,31.95,,81.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,168.416,case rate,pays based on per visit rate,204.16,31.95,,89.464,Fee Schedule,31.95% of LA custom fee schedule,872.94,2524,
INTRODUCTION NEEDLE INTRACATH VEIN,3500509,CDM,450,RC,36000,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,1.78,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,10.336,fee schedule,136.60% of BCBS custom fee schedule,26.36,35.15,,168.72,fee schedule,35.15% of LA custom fee schedule,23.96,31.95,,81.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.5,38,,168.416,percent of total billed charges,38% of total billed charges,23.96,31.95,,153.36,Fee Schedule,31.95% of LA custom fee schedule,873.94,2525,
PUNCH BIOPSY SKIN SINGLE LESION,3500523,CDM,450,RC,11104,HCPCS,OUTPATIENT,,,985,591,,837.25,85,,669.8,Percent of total billed charges,85% of total billed charges,742.27,136.6,,10.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,742.27,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,346.23,35.15,,163.328,fee schedule,35.15% of LA custom fee schedule,314.71,31.95,,163.328,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,374.3,38,,168.416,percent of total billed charges,38% of total billed charges,314.71,31.95,,204.48,Fee Schedule,31.95% of LA custom fee schedule,874.94,2526,
REMOVAL IMPACT CERUM LAV UNLA,3500524,CDM,450,RC,69209,HCPCS,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,235.32,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,235.32,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,73.82,35.15,,885.784,fee schedule,35.15% of LA custom fee schedule,67.1,31.95,,82.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,79.8,38,,121.904,percent of total billed charges,38% of total billed charges,67.1,31.95,,805.144,Fee Schedule,31.95% of LA custom fee schedule,875.94,2527,
AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR,3500530,CDM,450,RC,26951,HCPCS,OUTPATIENT,,,5475,3285,,4653.75,85,,3723,Percent of total billed charges,85% of total billed charges,3915.28,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3915.28,136.6,,117.2,fee schedule,136.60% of BCBS custom fee schedule,1749.26,31.95,,674.88,percent of total billed charges,31.95% of total billed charges,1749.26,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2080.5,38,,121.904,percent of total billed charges,38% of total billed charges,2190,40,,613.44,percent of total billed charges,40% of total billed charges,876.94,2528,
CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA,3500533,CDM,450,RC,26750,HCPCS,OUTPATIENT,,,650,390,,552.5,85,,442,Percent of total billed charges,85% of total billed charges,430.58,136.6,,117.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,92.8,fee schedule,136.60% of BCBS custom fee schedule,228.48,35.15,,383.4,fee schedule,35.15% of LA custom fee schedule,207.68,31.95,,383.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,247,38,,121.904,percent of total billed charges,38% of total billed charges,207.68,31.95,,480,Fee Schedule,31.95% of LA custom fee schedule,877.94,2529,
CLTX DSTL FIBULAR FX LAT MALLS W/MANJ 27788,3500540,CDM,450,RC,27788,HCPCS,OUTPATIENT,,,615,369,,522.75,85,,418.2,Percent of total billed charges,85% of total billed charges,861.18,136.6,,92.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,92.8,fee schedule,136.60% of BCBS custom fee schedule,196.49,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,196.49,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,233.7,38,,159.6,percent of total billed charges,38% of total billed charges,246,40,,480,percent of total billed charges,40% of total billed charges,878.94,2530,
CLTX HIP DISLOCATION TRAUMATIC REQ ANES,3500541,CDM,450,RC,27252,HCPCS,OUTPATIENT,,,3690,2214,,3136.5,85,,2509.2,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,92.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,1178.96,31.95,,54.696,percent of total billed charges,31.95% of total billed charges,1178.96,31.95,,54.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1402.2,38,,159.6,percent of total billed charges,38% of total billed charges,1476,40,,68.48,percent of total billed charges,40% of total billed charges,879.94,2531,
CLTX POST HIP ARTHRP DISLC REQ ANES,3500546,CDM,450,RC,27266,HCPCS,OUTPATIENT,,,3690,2214,,3136.5,85,,2509.2,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,1178.96,31.95,,54.696,percent of total billed charges,31.95% of total billed charges,1178.96,31.95,,54.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1402.2,38,,159.6,percent of total billed charges,38% of total billed charges,1476,40,,68.48,percent of total billed charges,40% of total billed charges,880.94,2532,
NEG PRESS WOUND TX DME </=50 CM,3500550,CDM,360,RC,97605,HCPCS,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,212.22,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,5.432,fee schedule,136.60% of BCBS custom fee schedule,111.83,31.95,,1.688,percent of total billed charges,31.95% of total billed charges,111.83,31.95,,8.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,70.528,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,140,40,,1.536,percent of total billed charges,40% of total billed charges,881.94,2533,
NEG PRESS WOUND TX DME >50 SQ CM,3500551,CDM,360,RC,97606,HCPCS,OUTPATIENT,,,655,393,,556.75,85,,445.4,Percent of total billed charges,85% of total billed charges,265.45,136.6,,5.432,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.45,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,209.27,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,209.27,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,121.904,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,262,40,,576,percent of total billed charges,40% of total billed charges,882.94,2534,
NPWT NON DME </= 50 SQ CM,3500552,CDM,360,RC,97607,HCPCS,OUTPATIENT,,,600,360,,510,85,,408,Percent of total billed charges,85% of total billed charges,390.74,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,390.74,136.6,,5.232,fee schedule,136.60% of BCBS custom fee schedule,191.7,31.95,,446.792,percent of total billed charges,31.95% of total billed charges,191.7,31.95,,446.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,121.904,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,240,40,,559.36,percent of total billed charges,40% of total billed charges,883.94,2535,
NPWT NON DME >50 SQ CM,3500553,CDM,360,RC,97608,HCPCS,OUTPATIENT,,,655,393,,556.75,85,,445.4,Percent of total billed charges,85% of total billed charges,390.74,136.6,,5.232,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,390.74,136.6,,25.6,fee schedule,136.60% of BCBS custom fee schedule,209.27,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,209.27,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,121.904,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,262,40,,512,percent of total billed charges,40% of total billed charges,884.94,2536,
Pre-OP Services Flat Charge,3500555,CDM,360,RC,,,OUTPATIENT,,,320,192,,272,85,,217.6,Percent of total billed charges,85% of total billed charges,160,50,,25.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,160,50,,53.2,percent of total billed charges,50% of total billed charges,102.24,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,102.24,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.6,38,,121.904,percent of total billed charges,38% of total billed charges,128,40,,544,percent of total billed charges,40% of total billed charges,885.94,2537,
Additional Personnel Per 30 Minutes,3500556,CDM,360,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,53.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,5.6,percent of total billed charges,50% of total billed charges,28.76,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,121.904,percent of total billed charges,38% of total billed charges,36,40,,480,percent of total billed charges,40% of total billed charges,886.94,2538,
Unscheduled/Emergent Case Charge,3500557,CDM,360,RC,,,OUTPATIENT,,,950,570,,807.5,85,,646,Percent of total billed charges,85% of total billed charges,475,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,475,50,,124,percent of total billed charges,50% of total billed charges,303.53,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,303.53,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,361,38,,121.904,percent of total billed charges,38% of total billed charges,380,40,,448,percent of total billed charges,40% of total billed charges,887.94,2539,
COMPUT ASSIST SURG NAV MS PROC,3500560,CDM,360,RC,20985,HCPCS,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,1.78,136.6,,124,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,121.904,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,200,40,,576,percent of total billed charges,40% of total billed charges,888.94,2540,
ROBOTIC SURGICAL SYSTEM,3500565,CDM,360,RC,S2900,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,50,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,1.624,percent of total billed charges,50% of total billed charges,31.95,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38,38,,121.904,percent of total billed charges,38% of total billed charges,40,40,,512,percent of total billed charges,40% of total billed charges,889.94,2541,
SPINAL PUNCTURE,3500570,CDM,361,RC,62270,HCPCS,OUTPATIENT,,,1416,849.6,,1203.6,85,,962.88,Percent of total billed charges,85% of total billed charges,567.44,136.6,,1.624,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,452.41,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,452.41,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,121.904,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,566.4,40,,448,percent of total billed charges,40% of total billed charges,890.94,2542,
Scope Each - Any Type,3500580,CDM,360,RC,,,OUTPATIENT,,,340,204,,289,85,,231.2,Percent of total billed charges,85% of total billed charges,170,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,170,50,,4.224,percent of total billed charges,50% of total billed charges,108.63,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,108.63,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.2,38,,52.472,percent of total billed charges,38% of total billed charges,136,40,,448,percent of total billed charges,40% of total billed charges,891.94,2543,
Video Tower,3500581,CDM,360,RC,,,OUTPATIENT,,,700,420,,595,85,,476,Percent of total billed charges,85% of total billed charges,350,50,,4.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,350,50,,7.6,percent of total billed charges,50% of total billed charges,223.65,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,223.65,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,266,38,,52.472,percent of total billed charges,38% of total billed charges,280,40,,448,percent of total billed charges,40% of total billed charges,892.94,2544,
Insufflator,3500582,CDM,360,RC,,,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,5.6,percent of total billed charges,50% of total billed charges,22.37,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.6,38,,52.472,percent of total billed charges,38% of total billed charges,28,40,,448,percent of total billed charges,40% of total billed charges,893.94,2545,
Arthroscopy Shaver Unit,3500583,CDM,360,RC,,,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,47.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47.5,50,,9.904,percent of total billed charges,50% of total billed charges,30.35,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,30.35,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.1,38,,121.904,percent of total billed charges,38% of total billed charges,38,40,,448,percent of total billed charges,40% of total billed charges,894.94,2546,
Arthocare Unit - RF Ablation Device,3500584,CDM,360,RC,,,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,62.5,50,,9.904,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,62.5,50,,3.472,percent of total billed charges,50% of total billed charges,39.94,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.5,38,,121.904,percent of total billed charges,38% of total billed charges,50,40,,448,percent of total billed charges,40% of total billed charges,895.94,2547,
Power Set (Drills/Saws),3500585,CDM,360,RC,,,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,75,50,,3.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75,50,,74.8,percent of total billed charges,50% of total billed charges,47.93,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,121.904,percent of total billed charges,38% of total billed charges,60,40,,448,percent of total billed charges,40% of total billed charges,896.94,2548,
INTRO ANY HEMO AGENT/PACK VAG HEMRRG,3500780,CDM,450,RC,57180,HCPCS,OUTPATIENT,,,505,303,,429.25,85,,343.4,Percent of total billed charges,85% of total billed charges,595.96,136.6,,74.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,161.35,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,161.35,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,191.9,38,,45.6,percent of total billed charges,38% of total billed charges,202,40,,448,percent of total billed charges,40% of total billed charges,897.94,2549,
BAIR HUGGER BLOOD WARMING COIL,3501007,CDM,270,RC,,,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,63.96,percent of total billed charges,50% of total billed charges,23.96,31.95,,446.792,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,446.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,245.936,percent of total billed charges,38% of total billed charges,30,40,,559.36,percent of total billed charges,40% of total billed charges,898.94,2550,
7-BAND LIGATOR,3501011,CDM,272,RC,,,OUTPATIENT,,,501.38,300.828,,426.17,85,,340.936,Percent of total billed charges,85% of total billed charges,250.69,50,,63.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250.69,50,,50,percent of total billed charges,50% of total billed charges,160.19,31.95,,350.68,percent of total billed charges,31.95% of total billed charges,160.19,31.95,,350.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190.52,38,,148.96,percent of total billed charges,38% of total billed charges,200.55,40,,439.04,percent of total billed charges,40% of total billed charges,899.94,2551,
INTRODUCER VENUS ACCESS KIT,3501014,CDM,278,RC,C1788,HCPCS,OUTPATIENT,,,188,112.8,,197.4,105,,,case rate,pays based on 105% of threshold rate,94,50,,50,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,94,50,,1.6,percent of total billed charges,50% of total billed charges,66.08,35.15,,350.68,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,350.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.44,38,,210.976,percent of total billed charges,38% of total billed charges,60.07,31.95,,439.04,percent of total billed charges,31.95% of total billed charges,900.94,2552,
PORT IMPLANTABLE POWERPORT VUE,3501015,CDM,278,RC,C1788,HCPCS,OUTPATIENT,,,2300,1380,,2415,105,,,case rate,pays based on 105% of threshold rate,1150,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1150,50,,48.8,percent of total billed charges,50% of total billed charges,808.45,35.15,,350.68,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,350.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,874,38,,210.976,percent of total billed charges,38% of total billed charges,734.85,31.95,,439.04,percent of total billed charges,31.95% of total billed charges,901.94,2553,
CHEMOSITE PORT INFUSION CATHETER,3501016,CDM,278,RC,C1788,HCPCS,OUTPATIENT,,,1170,702,,1228.5,105,,,case rate,pays based on 105% of threshold rate,585,50,,48.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,585,50,,3.6,percent of total billed charges,50% of total billed charges,411.26,35.15,,350.68,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,350.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,444.6,38,,210.976,percent of total billed charges,38% of total billed charges,373.82,31.95,,439.04,percent of total billed charges,31.95% of total billed charges,902.94,2554,
Extended Recovery FMC,3510001,CDM,710,RC,,,OUTPATIENT,,,375,225,,318.75,85,,255,Percent of total billed charges,85% of total billed charges,187.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,187.5,50,,2,percent of total billed charges,50% of total billed charges,119.81,31.95,,350.68,percent of total billed charges,31.95% of total billed charges,119.81,31.95,,350.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,1141.824,other,Not separately reimbursable,150,40,,439.04,percent of total billed charges,40% of total billed charges,903.94,2555,
00100 ANESTHESIA SALIVARY GLANDS W/BX FMC CHARGE,3520001,CDM,964,RC,100,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,350.68,other,Not separately reimbursable,,31.95,,350.68,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,1141.824,other,Not separately reimbursable,,,,439.04,other,Not separately reimbursable,904.94,2556,
00120 ANESTHESIA EAR SURGERY FMC CHARGE,3520002,CDM,964,RC,120,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,1.248,other,Not separately reimbursable,,,,350.68,other,Not separately reimbursable,,31.95,,350.68,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,1141.824,other,Not separately reimbursable,,,,439.04,other,Not separately reimbursable,905.94,2557,
00126 ANESTHESIA TYMPANOTOMY FMC CHARGE,3520003,CDM,370,RC,126,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,1.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,4.304,percent of total billed charges,50% of total billed charges,26.36,35.15,,434.52,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,638.4,percent of total billed charges,38% of total billed charges,23.96,31.95,,544,percent of total billed charges,31.95% of total billed charges,906.94,2558,
00160 ANESTHESIA NOSE/SINUS SURGERY FMC CHARGE,3520004,CDM,964,RC,160,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,4.304,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,16.4,other,Not separately reimbursable,,,,357.84,other,Not separately reimbursable,,31.95,,357.84,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,638.4,other,Not separately reimbursable,,,,448,other,Not separately reimbursable,907.94,2559,
00170 ANESTHESIA PROCEDURE ON MOUTH FMC CHARGE,3520005,CDM,964,RC,170,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,16.4,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,0.8,other,Not separately reimbursable,,,,434.52,other,Not separately reimbursable,,31.95,,434.52,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,638.4,other,Not separately reimbursable,,,,544,other,Not separately reimbursable,908.94,2560,
00174 ANESTHESIA PHARYNGEAL SURGERY FMC CHARGE,3520006,CDM,964,RC,174,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,0.8,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,35.6,other,Not separately reimbursable,,,,357.84,other,Not separately reimbursable,,31.95,,357.84,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,448,other,Not separately reimbursable,909.94,2561,
00300 ANESTHESIA HEAD/NECK/PTRUNK FMC CHARGE,3520007,CDM,964,RC,300,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,35.6,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,15.2,other,Not separately reimbursable,,,,281.16,other,Not separately reimbursable,,31.95,,281.16,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,99.408,other,Not separately reimbursable,,,,352,other,Not separately reimbursable,910.94,2562,
00320 ANESTHESIA NECK ORGAN 1YR/> FMC CHARGE,3520008,CDM,964,RC,320,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,15.2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,16.4,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,99.408,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,911.94,2563,
00400 ANESTHESIA SKIN EXT/PER/ATRUNK FMC CHARGE,3520009,CDM,964,RC,400,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,16.4,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,14.8,other,Not separately reimbursable,,,,2634.216,other,Not separately reimbursable,,31.95,,2634.216,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,99.408,other,Not separately reimbursable,,,,3297.92,other,Not separately reimbursable,912.94,2564,
00404 ANESTHESIA SURGERY OF BREAST FMC CHARGE,3520010,CDM,964,RC,404,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,14.8,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,13.6,other,Not separately reimbursable,,,,2634.216,other,Not separately reimbursable,,31.95,,2634.216,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,3297.92,other,Not separately reimbursable,913.94,2565,
00520 ANESTHESIA CHEST PROCEDURE FMC CHARGE,3520011,CDM,964,RC,520,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,13.6,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,10.88,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,405.84,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,914.94,2566,
00524 ANESTHESIA CHEST DRAINAGE FMC CHARGE,3520012,CDM,964,RC,524,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,10.88,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,11.6,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,405.84,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,915.94,2567,
00532 ANESTHESIA VASCULAR ACCESS FMC CHARGE,3520013,CDM,964,RC,532,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,11.6,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,11.2,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,916.94,2568,
00534 ANESTHESIA CARDIOVERTER/DEFIB FMC CHARGE,3520014,CDM,964,RC,534,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,11.2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,2.4,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,917.94,2569,
00700 ANESTHESIA ABDOMINAL WALL SURG FMC CHARGE,3520015,CDM,964,RC,700,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,2.4,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,7.6,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,918.94,2570,
00750 ANESTHESIA REPAIR OF HERNIA UP AB NOS FMC CHARGE,3520017,CDM,964,RC,750,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,7.6,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,7.6,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,919.94,2571,
00752 ANESTHESIA REPAIR OF HERNIA UPPER FMC CHARGE,3520018,CDM,964,RC,752,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,7.6,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,9.6,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,920.94,2572,
00790 ANESTHESIA SURG UPPER ABDOMEN FMC CHARGE,3520019,CDM,964,RC,790,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,9.6,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,10.8,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,921.94,2573,
00800 ANESTHESIA ABDOMINAL WALL SURG FMC CHARGE,3520020,CDM,964,RC,800,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,10.8,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,340.56,other,Not separately reimbursable,,,,460.08,other,Not separately reimbursable,,31.95,,460.08,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,99.408,other,Not separately reimbursable,,,,576,other,Not separately reimbursable,922.94,2574,
00830 ANESTHESIA HERNIA REPAIR LOWER ABD FMC CHARGE,3520022,CDM,964,RC,830,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,340.56,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,1.2,other,Not separately reimbursable,,,,434.52,other,Not separately reimbursable,,31.95,,434.52,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,1098.96,other,Not separately reimbursable,,,,544,other,Not separately reimbursable,923.94,2575,
00832 VENTRAL  INCISION HERNIA CHARGE,3520023,CDM,370,RC,832,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,161.968,percent of total billed charges,50% of total billed charges,26.36,35.15,,148.248,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,188.48,percent of total billed charges,38% of total billed charges,23.96,31.95,,185.6,percent of total billed charges,31.95% of total billed charges,924.94,2576,
00836 ANESTHESIA HERNIA REPAIR PREEMIE FMC CHARGE,3520024,CDM,964,RC,836,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,161.968,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,16.4,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,925.94,2577,
00840 ANESTHESIA SURG LOWER ABDOMEN FMC CHARGE,3520025,CDM,964,RC,840,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,16.4,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,13.504,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,373.92,other,Not separately reimbursable,,,,480,other,Not separately reimbursable,926.94,2578,
00860 ANESTHESIA SURGERY OF ABDOMEN FMC CHARGE,3520026,CDM,964,RC,860,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,13.504,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,47.176,other,Not separately reimbursable,,,,306.72,other,Not separately reimbursable,,31.95,,306.72,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,373.92,other,Not separately reimbursable,,,,384,other,Not separately reimbursable,927.94,2579,
00862 ANESTHESIA KIDNEY/URETER SURG FMC CHARGE,3520027,CDM,964,RC,862,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,47.176,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,0.4,other,Not separately reimbursable,,,,306.72,other,Not separately reimbursable,,31.95,,306.72,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,373.92,other,Not separately reimbursable,,,,384,other,Not separately reimbursable,928.94,2580,
00870 ANESTHESIA BLADDER STONE SURG FMC CHARGE,3520028,CDM,964,RC,870,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,0.4,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,148.248,other,Not separately reimbursable,,31.95,,148.248,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,185.6,other,Not separately reimbursable,929.94,2581,
00872 ANESTHESIA KIDNEY STONE DESTRUCT FMC CHARGE,3520029,CDM,964,RC,872,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,1.2,other,Not separately reimbursable,,,,1.536,other,Not separately reimbursable,,31.95,,1.536,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,1.92,other,Not separately reimbursable,930.94,2582,
00873 ANESTHESIA KIDNEY STONE DESTRUCT FMC CHARGE,3520030,CDM,964,RC,873,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,1.2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,18.52,other,Not separately reimbursable,,,,105.448,other,Not separately reimbursable,,31.95,,84.352,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,95.848,other,Not separately reimbursable,931.94,2583,
00902 ANESTHESIA ANORECTAL SURGERY FMC CHARGE,3520031,CDM,964,RC,902,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,18.52,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,8.232,other,Not separately reimbursable,,,,4.216,other,Not separately reimbursable,,31.95,,84.352,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,3.832,other,Not separately reimbursable,932.94,2584,
00904 ANESTHESIA RADICAL PERINEAL FMC CHARGE,3520032,CDM,964,RC,904,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,8.232,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,,,,196.84,other,Not separately reimbursable,,31.95,,84.352,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,178.92,other,Not separately reimbursable,933.94,2585,
00910 ANESTHESIA BLADDER SURGERY FMC CHARGE,3520033,CDM,964,RC,910,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,84.36,other,Not separately reimbursable,,31.95,,84.352,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,76.68,other,Not separately reimbursable,934.94,2586,
00912 ANESTHESIA BLADDER TUMOR SURG FMC CHARGE,3520034,CDM,964,RC,912,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,7.024,other,Not separately reimbursable,,,,295.264,other,Not separately reimbursable,,31.95,,84.352,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,373.008,other,Not separately reimbursable,,,,268.384,other,Not separately reimbursable,935.94,2587,
00914 ANESTHESIA REMOVAL OF PROSTATE FMC CHARGE,3520035,CDM,964,RC,914,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,7.024,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,2.8,other,Not separately reimbursable,,,,42.184,other,Not separately reimbursable,,31.95,,84.352,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,373.008,other,Not separately reimbursable,,,,38.344,other,Not separately reimbursable,936.94,2588,
00918 ANESTHESIA STONE REMOVAL FMC CHARGE,3520036,CDM,964,RC,918,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,2.8,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,14.064,other,Not separately reimbursable,,31.95,,84.352,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,373.008,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,937.94,2589,
00920 ANESTHESIA GENITALIA SURGERY FMC CHARGE,3520037,CDM,964,RC,920,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,15.2,other,Not separately reimbursable,,,,14.296,other,Not separately reimbursable,,31.95,,14.296,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,1403.872,other,Not separately reimbursable,,,,17.904,other,Not separately reimbursable,938.94,2590,
00921 ANESTHESIA VASECTOMY FMC CHARGE,3520038,CDM,964,RC,921,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,15.2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,46.08,other,Not separately reimbursable,,,,28.12,other,Not separately reimbursable,,31.95,,84.6,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,1403.872,other,Not separately reimbursable,,,,25.56,other,Not separately reimbursable,939.94,2591,
00924 ANESTHESIA TESTIS EXPLORATION FMC CHARGE,3520039,CDM,964,RC,924,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,46.08,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,138.24,other,Not separately reimbursable,,,,364.432,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,1403.872,other,Not separately reimbursable,,,,331.256,other,Not separately reimbursable,940.94,2592,
00942 ANESTHESIA SURG ON VAG/URETHRAL FMC CHARGE,3520040,CDM,964,RC,942,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,138.24,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,90,other,Not separately reimbursable,,,,47.24,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,42.944,other,Not separately reimbursable,941.94,2593,
01230 ANESTHESIA SURGERY OF FEMUR FMC CHARGE,3520041,CDM,964,RC,1230,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,90,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,75.6,other,Not separately reimbursable,,,,16.872,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,942.94,2594,
01232 ANESTHESIA AMPUTATION FEMUR FMC CHARGE,3520042,CDM,964,RC,1232,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,75.6,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,5.2,other,Not separately reimbursable,,,,400.712,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,210.976,other,Not separately reimbursable,,,,364.232,other,Not separately reimbursable,943.94,2595,
01250 ANESTHESIA UPPER LEG SURGERY FMC CHARGE,3520043,CDM,964,RC,1250,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,5.2,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,8.4,other,Not separately reimbursable,,,,379.624,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,102.144,other,Not separately reimbursable,,,,345.064,other,Not separately reimbursable,944.94,2596,
01462 ANESTHESIA LOWER LEG ANKLE  FOOT FMC CHARGE,3520044,CDM,964,RC,1462,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,8.4,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,8,other,Not separately reimbursable,,,,843.6,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,102.144,other,Not separately reimbursable,,,,766.8,other,Not separately reimbursable,945.94,2597,
01470 ANESTHESIA LOWER LEG SURGERY FMC CHARGE,3520045,CDM,964,RC,1470,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,8,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,11.472,other,Not separately reimbursable,,,,42.184,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,102.144,other,Not separately reimbursable,,,,38.344,other,Not separately reimbursable,946.94,2598,
01480 ANESTHESIA LOWER LEG BONE SURG FMC CHARGE,3520046,CDM,964,RC,1480,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,11.472,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,159.016,other,Not separately reimbursable,,,,98.136,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,131.632,other,Not separately reimbursable,,,,89.208,other,Not separately reimbursable,947.94,2599,
01610 ANESTHESIA SURGERY OF SHOULDER FMC CHARGE,3520047,CDM,964,RC,1610,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,159.016,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,560,other,Not separately reimbursable,,,,26.992,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,131.632,other,Not separately reimbursable,,,,24.536,other,Not separately reimbursable,948.94,2600,
01810 ANESTHESIA LOWER ARM SURGERY FMC CHARGE,3520048,CDM,964,RC,1810,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,560,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,15.2,other,Not separately reimbursable,,,,101.232,other,Not separately reimbursable,,31.95,,84.856,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,131.632,other,Not separately reimbursable,,,,92.016,other,Not separately reimbursable,949.94,2601,
01922 ANESTHESIA CT OR MRI SCAN FMC CHARGE,3520049,CDM,370,RC,1922,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.01,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,26.36,35.15,,28.68,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,84.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,1522.736,percent of total billed charges,38% of total billed charges,23.96,31.95,,26.072,percent of total billed charges,31.95% of total billed charges,950.94,2602,
01120 ANESTHESIA ON BONY PELVIS FMC CHARGE,3520050,CDM,370,RC,1120,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,13.2,percent of total billed charges,50% of total billed charges,26.36,35.15,,28.68,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,84.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,1522.736,percent of total billed charges,38% of total billed charges,23.96,31.95,,26.072,percent of total billed charges,31.95% of total billed charges,951.94,2603,
SPINAL/EPIDURAL PER OCCURRENCE,3520105,CDM,370,RC,,,OUTPATIENT,,,600,360,,510,85,,408,Percent of total billed charges,85% of total billed charges,300,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,300,50,,50.4,percent of total billed charges,50% of total billed charges,191.7,31.95,,25.312,percent of total billed charges,31.95% of total billed charges,191.7,31.95,,84.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,1522.736,percent of total billed charges,38% of total billed charges,240,40,,23.008,percent of total billed charges,40% of total billed charges,952.94,2604,
Regional Block,3520106,CDM,370,RC,,,OUTPATIENT,,,600,360,,510,85,,408,Percent of total billed charges,85% of total billed charges,300,50,,50.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,300,50,,229.6,percent of total billed charges,50% of total billed charges,191.7,31.95,,2421.256,percent of total billed charges,31.95% of total billed charges,191.7,31.95,,85.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,210.976,percent of total billed charges,38% of total billed charges,240,40,,2200.832,percent of total billed charges,40% of total billed charges,953.94,2605,
ANESTHESIA GAS PER 30 MINUTES,3520110,CDM,250,RC,,,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,229.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,229.6,percent of total billed charges,50% of total billed charges,23.96,31.95,,364.432,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,210.976,percent of total billed charges,38% of total billed charges,30,40,,331.256,percent of total billed charges,40% of total billed charges,954.94,2606,
Report,3548567,CDM,972,RC,47000,HCPCS,OUTPATIENT,,,1015,609,26,,,,,other,Not separately reimbursable,,,,229.6,other,Not separately reimbursable,445.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,3.2,other,Not separately reimbursable,,,,84.36,other,Not separately reimbursable,,31.95,,85.88,other,Not separately reimbursable,82.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,210.976,other,Not separately reimbursable,,,,76.68,other,Not separately reimbursable,955.94,2607,
US Biopsy Liver,3548567,CDM,360,RC,47000,HCPCS,OUTPATIENT,,,3031,1818.6,26,2576.35,85,,2061.08,Percent of total billed charges,85% of total billed charges,1502.91,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1502.91,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,968.4,31.95,,42.744,percent of total billed charges,31.95% of total billed charges,968.4,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,101.84,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1212.4,40,,38.848,percent of total billed charges,40% of total billed charges,956.94,2608,
CT Abdomen/Pelvis w/ Contrast,3556370,CDM,350,RC,74177,HCPCS,OUTPATIENT,,,1950,1170,TC,1657.5,85,,1326,Percent of total billed charges,85% of total billed charges,1013.12,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1013.12,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,126.544,fee schedule,35.15% of LA custom fee schedule,623.03,31.95,,86.904,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,102.448,case rate,pays based on per visit rate,623.03,31.95,,115.024,Fee Schedule,31.95% of LA custom fee schedule,957.94,2609,
Report,3556370,CDM,972,RC,74177,HCPCS,OUTPATIENT,,,275,165,TC,,,,,other,Not separately reimbursable,,,,1.2,other,Not separately reimbursable,399.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,1.2,other,Not separately reimbursable,,,,42.184,other,Not separately reimbursable,,31.95,,87.16,other,Not separately reimbursable,199.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,101.84,other,Not separately reimbursable,,,,38.344,other,Not separately reimbursable,958.94,2610,
CT Abdomen/Pelvis w/ Contrast,3556370,CDM,350,RC,74177,HCPCS,OUTPATIENT,,,1950,1170,TC,1657.5,85,,1326,Percent of total billed charges,85% of total billed charges,1013.12,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1013.12,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,43.864,fee schedule,35.15% of LA custom fee schedule,623.03,31.95,,88.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,167.2,case rate,pays based on per visit rate,623.03,31.95,,39.872,Fee Schedule,31.95% of LA custom fee schedule,959.94,2611,
CT Abdomen/Pelvis w/ Contrast Profee,3556370,CDM,972,RC,74177,HCPCS,OUTPATIENT,,,275,165,TC,,,,,other,Not separately reimbursable,,,,1.2,other,Not separately reimbursable,399.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,45.144,other,Not separately reimbursable,,,,224.96,other,Not separately reimbursable,,31.95,,88.184,other,Not separately reimbursable,199.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,196.992,other,Not separately reimbursable,,,,204.48,other,Not separately reimbursable,960.94,2612,
71260 CT Chest/Abdomen/Pelvis w/contrast Tech,3556370,CDM,350,RC,71260,HCPCS,OUTPATIENT,,,1200,720,TC,1020,85,,816,Percent of total billed charges,85% of total billed charges,796.77,136.6,,45.144,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,33.6,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,357.688,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,88.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,197.6,case rate,pays based on per visit rate,383.4,31.95,,325.12,Fee Schedule,31.95% of LA custom fee schedule,961.94,2613,
SEVOFLURANE 240 ML,3700028,CDM,250,RC,,,OUTPATIENT,,,352,211.2,,299.2,85,,239.36,Percent of total billed charges,85% of total billed charges,176,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,176,50,,1.2,percent of total billed charges,50% of total billed charges,112.46,31.95,,357.688,percent of total billed charges,31.95% of total billed charges,112.46,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133.76,38,,179.36,percent of total billed charges,38% of total billed charges,140.8,40,,325.12,percent of total billed charges,40% of total billed charges,962.94,2614,
FORANE 100 ML,3700044,CDM,370,RC,,,OUTPATIENT,,,352,211.2,,299.2,85,,239.36,Percent of total billed charges,85% of total billed charges,176,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,176,50,,15.12,percent of total billed charges,50% of total billed charges,112.46,31.95,,357.688,percent of total billed charges,31.95% of total billed charges,112.46,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133.76,38,,179.36,percent of total billed charges,38% of total billed charges,140.8,40,,325.12,percent of total billed charges,40% of total billed charges,963.94,2615,
"APPLICATION CAST ELBOW FINGER SHORT ARM, BILATERAL",3900001,CDM,450,RC,29075,HCPCS,OUTPATIENT,,,554,332.4,50,470.9,85,,376.72,Percent of total billed charges,85% of total billed charges,277,50,,15.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,277,50,,3.6,percent of total billed charges,50% of total billed charges,194.73,35.15,,42.184,fee schedule,35.15% of LA custom fee schedule,177,31.95,,88.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,210.52,38,,261.44,percent of total billed charges,38% of total billed charges,177,31.95,,38.344,Fee Schedule,31.95% of LA custom fee schedule,964.94,2616,
"APPLICATION CAST ELBOW FINGER SHORT ARM, LEFT",3900002,CDM,450,RC,29075,HCPCS,OUTPATIENT,,,554,332.4,,470.9,85,,376.72,Percent of total billed charges,85% of total billed charges,277,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,277,50,,10,percent of total billed charges,50% of total billed charges,194.73,35.15,,83.584,fee schedule,35.15% of LA custom fee schedule,177,31.95,,83.584,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,210.52,38,,32.224,percent of total billed charges,38% of total billed charges,177,31.95,,104.64,Fee Schedule,31.95% of LA custom fee schedule,965.94,2617,
"APPLICATION CAST ELBOW FINGER SHORT ARM, RIGHT",3900003,CDM,450,RC,29075,HCPCS,OUTPATIENT,,,554,332.4,,470.9,85,,376.72,Percent of total billed charges,85% of total billed charges,277,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,277,50,,10.8,percent of total billed charges,50% of total billed charges,194.73,35.15,,538.296,fee schedule,35.15% of LA custom fee schedule,177,31.95,,538.296,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,210.52,38,,120,percent of total billed charges,38% of total billed charges,177,31.95,,673.92,Fee Schedule,31.95% of LA custom fee schedule,966.94,2618,
"APPLICATION CAST HAND LOWER FOREARM , RIGHT",3900004,CDM,450,RC,29085,HCPCS,OUTPATIENT,,,401,240.6,,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,200.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,200.5,50,,0.8,percent of total billed charges,50% of total billed charges,140.95,35.15,,54.696,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,54.696,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,120,percent of total billed charges,38% of total billed charges,128.12,31.95,,68.48,Fee Schedule,31.95% of LA custom fee schedule,967.94,2619,
"APPLICATION CAST HAND LOWER FOREARM ,LEFT",3900005,CDM,450,RC,29085,HCPCS,OUTPATIENT,,,401,240.6,,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,200.5,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,200.5,50,,0.8,percent of total billed charges,50% of total billed charges,140.95,35.15,,54.696,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,54.696,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,120,percent of total billed charges,38% of total billed charges,128.12,31.95,,68.48,Fee Schedule,31.95% of LA custom fee schedule,968.94,2620,
"APPLICATION CAST HAND LOWER FOREARM, BILATERAL",3900006,CDM,450,RC,29085,HCPCS,OUTPATIENT,,,401,240.6,50,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,200.5,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,200.5,50,,2,percent of total billed charges,50% of total billed charges,140.95,35.15,,478.04,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,88.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,165.6,percent of total billed charges,38% of total billed charges,128.12,31.95,,434.52,Fee Schedule,31.95% of LA custom fee schedule,969.94,2621,
"APPLICATION CAST LONG ARM, BILATERAL",3900007,CDM,450,RC,29065,HCPCS,OUTPATIENT,,,525,315,50,446.25,85,,357,Percent of total billed charges,85% of total billed charges,262.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,262.5,50,,3.6,percent of total billed charges,50% of total billed charges,184.54,35.15,,28.12,fee schedule,35.15% of LA custom fee schedule,167.74,31.95,,88.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,199.5,38,,165.6,percent of total billed charges,38% of total billed charges,167.74,31.95,,25.56,Fee Schedule,31.95% of LA custom fee schedule,970.94,2622,
"APPLICATION CAST LONG ARM, LEFT",3900008,CDM,450,RC,29065,HCPCS,OUTPATIENT,,,525,315,,446.25,85,,357,Percent of total billed charges,85% of total billed charges,262.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,262.5,50,,392,percent of total billed charges,50% of total billed charges,184.54,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,167.74,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,199.5,38,,165.6,percent of total billed charges,38% of total billed charges,167.74,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,971.94,2623,
"APPLICATION CAST LONG ARM, RIGHT",3900009,CDM,450,RC,29065,HCPCS,OUTPATIENT,,,525,315,,446.25,85,,357,Percent of total billed charges,85% of total billed charges,262.5,50,,392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,262.5,50,,537.6,percent of total billed charges,50% of total billed charges,184.54,35.15,,357.84,fee schedule,35.15% of LA custom fee schedule,167.74,31.95,,357.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,199.5,38,,380,percent of total billed charges,38% of total billed charges,167.74,31.95,,448,Fee Schedule,31.95% of LA custom fee schedule,972.94,2624,
APPLICATION FINGER SPLINT STATIC,3900010,CDM,450,RC,29130,HCPCS,OUTPATIENT,,,232,139.2,,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,235.32,136.6,,537.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,235.32,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,81.55,35.15,,774.72,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,774.72,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,380,percent of total billed charges,38% of total billed charges,74.12,31.95,,969.92,Fee Schedule,31.95% of LA custom fee schedule,973.94,2625,
"APPLICATION LONG ARM SPLINT, BILATERAL",3900011,CDM,450,RC,29105,HCPCS,OUTPATIENT,,,401,240.6,50,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,4.784,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,88.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,380,percent of total billed charges,38% of total billed charges,128.12,31.95,,4.344,Fee Schedule,31.95% of LA custom fee schedule,974.94,2626,
"APPLICATION LONG ARM SPLINT, LEFT",3900012,CDM,450,RC,29105,HCPCS,OUTPATIENT,,,401,240.6,LT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,963.104,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,963.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,752,percent of total billed charges,38% of total billed charges,128.12,31.95,,1205.76,Fee Schedule,31.95% of LA custom fee schedule,975.94,2627,
"APPLICATION LONG ARM SPLINT, RIGHT",3900013,CDM,450,RC,29105,HCPCS,OUTPATIENT,,,401,240.6,RT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,302.888,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,302.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,752,percent of total billed charges,38% of total billed charges,128.12,31.95,,379.2,Fee Schedule,31.95% of LA custom fee schedule,976.94,2628,
"APPLICATION LONG LEG SPLINT, BILATERAL",3900014,CDM,450,RC,29505,HCPCS,OUTPATIENT,,,401,240.6,50,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,1446.184,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,1446.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,752,percent of total billed charges,38% of total billed charges,128.12,31.95,,1810.56,Fee Schedule,31.95% of LA custom fee schedule,977.94,2629,
"APPLICATION LONG LEG SPLINT, LEFT",3900015,CDM,450,RC,29505,HCPCS,OUTPATIENT,,,401,240.6,LT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,1446.184,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,1446.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,1393.6,percent of total billed charges,38% of total billed charges,128.12,31.95,,1810.56,Fee Schedule,31.95% of LA custom fee schedule,978.94,2630,
"APPLICATION LONG LEG SPLINT, RIGHT",3900016,CDM,450,RC,29505,HCPCS,OUTPATIENT,,,401,240.6,RT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,963.104,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,963.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,1393.6,percent of total billed charges,38% of total billed charges,128.12,31.95,,1205.76,Fee Schedule,31.95% of LA custom fee schedule,979.94,2631,
"APPLICATION SHORT ARM SPLINT STATIC, BILATERAL",3900017,CDM,450,RC,29125,HCPCS,OUTPATIENT,,,401,240.6,50,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,383.56,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,383.56,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,302.888,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,302.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,1393.6,percent of total billed charges,38% of total billed charges,128.12,31.95,,379.2,Fee Schedule,31.95% of LA custom fee schedule,980.94,2632,
"APPLICATION SHORT ARM SPLINT STATIC, LEFT",3900018,CDM,450,RC,29125,HCPCS,OUTPATIENT,,,401,240.6,LT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,383.56,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,383.56,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,963.104,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,963.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,73.872,percent of total billed charges,38% of total billed charges,128.12,31.95,,1205.76,Fee Schedule,31.95% of LA custom fee schedule,981.94,2633,
"APPLICATION SHORT ARM SPLINT STATIC, RIGHT",3900019,CDM,450,RC,29125,HCPCS,OUTPATIENT,,,401,240.6,RT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,383.56,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,383.56,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,963.104,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,963.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,904.4,percent of total billed charges,38% of total billed charges,128.12,31.95,,1205.76,Fee Schedule,31.95% of LA custom fee schedule,982.94,2634,
"APPLICATION SHORT LEG CAST, LEFT",3900020,CDM,450,RC,29405,HCPCS,OUTPATIENT,,,172.6,103.56,LT,146.71,85,,117.368,Percent of total billed charges,85% of total billed charges,86.3,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,86.3,50,,53.6,percent of total billed charges,50% of total billed charges,60.67,35.15,,302.888,fee schedule,35.15% of LA custom fee schedule,55.15,31.95,,302.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,65.59,38,,904.4,percent of total billed charges,38% of total billed charges,55.15,31.95,,379.2,Fee Schedule,31.95% of LA custom fee schedule,983.94,2635,
"APPLICATION SHORT LEG CAST, RIGHT",3900021,CDM,450,RC,29405,HCPCS,OUTPATIENT,,,172.6,103.56,RT,146.71,85,,117.368,Percent of total billed charges,85% of total billed charges,86.3,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,86.3,50,,86.4,percent of total billed charges,50% of total billed charges,60.67,35.15,,963.104,fee schedule,35.15% of LA custom fee schedule,55.15,31.95,,963.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,65.59,38,,904.4,percent of total billed charges,38% of total billed charges,55.15,31.95,,1205.76,Fee Schedule,31.95% of LA custom fee schedule,984.94,2636,
APPLICATION SHORT LEG CAST. BILATERAL,3900022,CDM,450,RC,29405,HCPCS,OUTPATIENT,,,172.6,103.56,50,146.71,85,,117.368,Percent of total billed charges,85% of total billed charges,86.3,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,86.3,50,,86.4,percent of total billed charges,50% of total billed charges,60.67,35.15,,302.888,fee schedule,35.15% of LA custom fee schedule,55.15,31.95,,302.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,65.59,38,,1540.368,percent of total billed charges,38% of total billed charges,55.15,31.95,,379.2,Fee Schedule,31.95% of LA custom fee schedule,985.94,2637,
"APPLICATION SHORT LEG SPLINT, BILATERAL",3900023,CDM,450,RC,29515,HCPCS,OUTPATIENT,,,401,240.6,50,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,963.104,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,963.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,68.4,percent of total billed charges,38% of total billed charges,128.12,31.95,,1205.76,Fee Schedule,31.95% of LA custom fee schedule,986.94,2638,
"APPLICATION SHORT LEG SPLINT, LEFT",3900024,CDM,450,RC,29515,HCPCS,OUTPATIENT,,,401,240.6,LT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,491.52,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,491.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,452.656,percent of total billed charges,38% of total billed charges,128.12,31.95,,615.36,Fee Schedule,31.95% of LA custom fee schedule,987.94,2639,
"APPLICATION SHORT LEG SPLINT, RIGHT",3900025,CDM,450,RC,29515,HCPCS,OUTPATIENT,,,401,240.6,RT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,501.61,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,302.888,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,302.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,430.464,percent of total billed charges,38% of total billed charges,128.12,31.95,,379.2,Fee Schedule,31.95% of LA custom fee schedule,988.94,2640,
ARTERIAL CATHETER/CANNULA PERCUTANEOUS,3900026,CDM,450,RC,36620,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,2787.99,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2787.99,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,491.52,fee schedule,35.15% of LA custom fee schedule,47.93,31.95,,491.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,817.456,percent of total billed charges,38% of total billed charges,47.93,31.95,,615.36,Fee Schedule,31.95% of LA custom fee schedule,989.94,2641,
"ARTHROCENTESIS, ASPIRATION, AND/OR INJECTIONS, SMALL JOINT OR BURSA (FINGERS, TO",3900027,CDM,450,RC,20600,HCPCS,OUTPATIENT,,,809,485.4,,687.65,85,,550.12,Percent of total billed charges,85% of total billed charges,567.44,136.6,,86.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,284.36,35.15,,963.104,fee schedule,35.15% of LA custom fee schedule,258.48,31.95,,963.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,307.42,38,,256.88,percent of total billed charges,38% of total billed charges,258.48,31.95,,1205.76,Fee Schedule,31.95% of LA custom fee schedule,990.94,2642,
CARDIAC TRANSCUTANEOUS PACING,3900028,CDM,450,RC,92953,HCPCS,OUTPATIENT,,,490,294,,416.5,85,,333.2,Percent of total billed charges,85% of total billed charges,615.38,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,615.38,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,172.24,35.15,,551.072,percent of total billed charges,35.15% of total billed charges,95.21,31.95,,551.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,186.2,38,,5596.032,percent of total billed charges,38% of total billed charges,156.56,31.95,,689.92,percent of total billed charges,31.95% of total billed charges,991.94,2643,
"CLOSED TREATMENT ANKLE DISLOCATION W/O ANESTHESIA, BILATERAL",3900030,CDM,450,RC,27840,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,496.12,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,496.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,48.64,percent of total billed charges,38% of total billed charges,277.6,40,,621.12,percent of total billed charges,40% of total billed charges,992.94,2644,
"CLOSED TREATMENT ANKLE DISLOCATION W/O ANESTHESIA, LEFT",3900031,CDM,450,RC,27840,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,472.864,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,472.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,161.12,percent of total billed charges,38% of total billed charges,277.6,40,,592,percent of total billed charges,40% of total billed charges,993.94,2645,
"CLOSED TREATMENT ANKLE DISLOCATION W/O ANESTHESIA, RIGHT",3900032,CDM,450,RC,27840,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,115.6,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,174.8,percent of total billed charges,38% of total billed charges,277.6,40,,3.064,percent of total billed charges,40% of total billed charges,994.94,2646,
"CLOSED TREATMENT FEMORAL SHAFT FRACTURE WITH MANIPULATION,  RIGHT",3900033,CDM,450,RC,27502,HCPCS,OUTPATIENT,,,3756,2253.6,RT,3192.6,85,,2554.08,Percent of total billed charges,85% of total billed charges,430.58,136.6,,115.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,115.6,fee schedule,136.60% of BCBS custom fee schedule,1200.04,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1200.04,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1427.28,38,,174.8,percent of total billed charges,38% of total billed charges,1502.4,40,,3.064,percent of total billed charges,40% of total billed charges,995.94,2647,
CLOSED TREATMENT FEMORAL SHAFT FRACTURE WITH MANIPULATION,3900034,CDM,450,RC,27502,HCPCS,OUTPATIENT,,,3756,2253.6,,3192.6,85,,2554.08,Percent of total billed charges,85% of total billed charges,430.58,136.6,,115.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,1200.04,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1200.04,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1427.28,38,,198.816,percent of total billed charges,38% of total billed charges,1502.4,40,,3.064,percent of total billed charges,40% of total billed charges,996.94,2648,
"CLOSED TREATMENT FEMORAL SHAFT FRACTURE WITH MANIPULATION, LEFT",3900035,CDM,450,RC,27502,HCPCS,OUTPATIENT,,,3756,2253.6,LT,3192.6,85,,2554.08,Percent of total billed charges,85% of total billed charges,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,1200.04,31.95,,143.416,percent of total billed charges,31.95% of total billed charges,1200.04,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1427.28,38,,198.816,percent of total billed charges,38% of total billed charges,1502.4,40,,130.36,percent of total billed charges,40% of total billed charges,997.94,2649,
"CLOSED TREATMENT INTERPHALANGEAL W ANESTHESIA, BILATERAL",3900036,CDM,450,RC,28665,HCPCS,OUTPATIENT,,,2100,1260,50,1785,85,,1428,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,670.95,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,670.95,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,242.288,percent of total billed charges,38% of total billed charges,840,40,,89.6,percent of total billed charges,40% of total billed charges,998.94,2650,
"CLOSED TREATMENT INTERPHALANGEAL W ANESTHESIA, LEFT",3900037,CDM,450,RC,28665,HCPCS,OUTPATIENT,,,2100,1260,,1785,85,,1428,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,670.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,670.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,242.288,percent of total billed charges,38% of total billed charges,840,40,,32,percent of total billed charges,40% of total billed charges,999.94,2651,
"CLOSED TREATMENT INTERPHALANGEAL W ANESTHESIA, RIGHT",3900038,CDM,450,RC,28665,HCPCS,OUTPATIENT,,,2100,1260,,1785,85,,1428,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,670.95,31.95,,33.744,percent of total billed charges,31.95% of total billed charges,670.95,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,242.288,percent of total billed charges,38% of total billed charges,840,40,,30.672,percent of total billed charges,40% of total billed charges,1000.94,2652,
CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID NAVICULAR);,3900040,CDM,450,RC,25635,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,7.536,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,159.752,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,159.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,242.288,percent of total billed charges,38% of total billed charges,277.6,40,,200,percent of total billed charges,40% of total billed charges,1001.94,2653,
"CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITHOUT MANIPULATION, BILATERAL",3900041,CDM,450,RC,23500,HCPCS,OUTPATIENT,,,327,196.2,50,277.95,85,,222.36,Percent of total billed charges,85% of total billed charges,430.58,136.6,,7.536,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,100.8,fee schedule,136.60% of BCBS custom fee schedule,104.48,31.95,,75.4,percent of total billed charges,31.95% of total billed charges,104.48,31.95,,75.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.26,38,,242.288,percent of total billed charges,38% of total billed charges,130.8,40,,94.4,percent of total billed charges,40% of total billed charges,1002.94,2654,
"CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITHOUT MANIPULATION, RIGHT",3900042,CDM,450,RC,23500,HCPCS,OUTPATIENT,,,327,196.2,RT,277.95,85,,222.36,Percent of total billed charges,85% of total billed charges,430.58,136.6,,100.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,104.48,31.95,,430.688,percent of total billed charges,31.95% of total billed charges,104.48,31.95,,430.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.26,38,,242.288,percent of total billed charges,38% of total billed charges,130.8,40,,539.2,percent of total billed charges,40% of total billed charges,1003.94,2655,
CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITHOUT MANIPULATION. LEFT,3900043,CDM,450,RC,23500,HCPCS,OUTPATIENT,,,327,196.2,LT,277.95,85,,222.36,Percent of total billed charges,85% of total billed charges,430.58,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,104.48,31.95,,486.92,percent of total billed charges,31.95% of total billed charges,104.48,31.95,,486.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.26,38,,241.984,percent of total billed charges,38% of total billed charges,130.8,40,,609.6,percent of total billed charges,40% of total billed charges,1004.94,2656,
"CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITH MANIPULATI",3900044,CDM,450,RC,26755,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,243.94,35.15,,153.36,fee schedule,35.15% of LA custom fee schedule,221.73,31.95,,153.36,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,263.72,38,,241.984,percent of total billed charges,38% of total billed charges,221.73,31.95,,192,Fee Schedule,31.95% of LA custom fee schedule,1005.94,2657,
Elec. Cardioversion 92960,3900045,CDM,480,RC,92960,HCPCS,OUTPATIENT,,,1325,795,,1126.25,85,,901,Percent of total billed charges,85% of total billed charges,1376.67,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1376.67,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,465.74,35.15,,14.056,fee schedule,35.15% of LA custom fee schedule,423.34,31.95,,14.056,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,494,100,,152,case rate,pays based on per visit rate,423.34,31.95,,17.6,Fee Schedule,31.95% of LA custom fee schedule,1006.94,2658,
CLO TREAT OF DIS RAD FRACT (COLLES OR SMITH TYPE) OR EPIP SEP W/O/W/O FRACT OF U,3900046,CDM,450,RC,25605,HCPCS,OUTPATIENT,,,1335,801,,1134.75,85,,907.8,Percent of total billed charges,85% of total billed charges,861.18,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,426.53,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,426.53,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,507.3,38,,241.984,percent of total billed charges,38% of total billed charges,534,40,,5.76,percent of total billed charges,40% of total billed charges,1007.94,2659,
CLO TREAT OF DIS RAD FRACT (COLLES OR SMITH TYPE) OR EPIP SEP W/O/W/O FRACT OF U,3900047,CDM,450,RC,25605,HCPCS,OUTPATIENT,,,1335,801,,1134.75,85,,907.8,Percent of total billed charges,85% of total billed charges,861.18,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,426.53,31.95,,4.64,percent of total billed charges,31.95% of total billed charges,426.53,31.95,,4.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,507.3,38,,242.288,percent of total billed charges,38% of total billed charges,534,40,,5.808,percent of total billed charges,40% of total billed charges,1008.94,2660,
CLO TRT OF DIS RAD FRACT (COLLES OR SMITH TYPE) O EPIP SEP W/O/WO FRACT OF ULNR,3900048,CDM,450,RC,25600,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,320,fee schedule,136.60% of BCBS custom fee schedule,243.94,35.15,,4.64,fee schedule,35.15% of LA custom fee schedule,221.73,31.95,,4.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,263.72,38,,242.288,percent of total billed charges,38% of total billed charges,221.73,31.95,,5.808,Fee Schedule,31.95% of LA custom fee schedule,1009.94,2661,
CLO TRT OF DIS RAD FRACT (COLLES OR SMITH TYPE) O EPIP SEP W/O/W/O FRACT OF ULNR,3900049,CDM,450,RC,25600,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,320,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,78.4,fee schedule,136.60% of BCBS custom fee schedule,243.94,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,221.73,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,263.72,38,,242.288,percent of total billed charges,38% of total billed charges,221.73,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,1010.94,2662,
CLO TR OF DIS RAD FRACT (COLLES OR SMITH TYPE) O EPIP SEP W/O/W/O FRACT OF ULNR,3900050,CDM,450,RC,25600,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,78.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,243.94,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,221.73,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,263.72,38,,242.288,percent of total billed charges,38% of total billed charges,221.73,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,1011.94,2663,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC,  W/O ANESTHESIA, BILATERAL",3900051,CDM,450,RC,27250,HCPCS,OUTPATIENT,,,694,416.4,50,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,497.952,percent of total billed charges,38% of total billed charges,277.6,40,,3.84,percent of total billed charges,40% of total billed charges,1012.94,2664,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC,  W/O ANESTHESIA, LEFT",3900052,CDM,450,RC,27250,HCPCS,OUTPATIENT,,,694,416.4,LT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,71.2,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,497.952,percent of total billed charges,38% of total billed charges,277.6,40,,3.84,percent of total billed charges,40% of total billed charges,1013.94,2665,
"CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC,  W/O ANESTHESIA, RIGHT",3900053,CDM,450,RC,27250,HCPCS,OUTPATIENT,,,694,416.4,RT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,71.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,121.296,percent of total billed charges,38% of total billed charges,277.6,40,,3.84,percent of total billed charges,40% of total billed charges,1014.94,2666,
"CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION",3900054,CDM,450,RC,26770,HCPCS,OUTPATIENT,,,327,196.2,,277.95,85,,222.36,Percent of total billed charges,85% of total billed charges,430.58,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,114.94,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,104.48,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,124.26,38,,242.288,percent of total billed charges,38% of total billed charges,104.48,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,1015.94,2667,
"CLOSED TREATMENT OF METACARPAL FRACTURE, WITH MANIPULATION, WITH EXTERNAL FIXATI",3900055,CDM,450,RC,26607,HCPCS,OUTPATIENT,,,3615,2169,,3072.75,85,,2458.2,Percent of total billed charges,85% of total billed charges,430.58,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,1154.99,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1154.99,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1373.7,38,,198.816,percent of total billed charges,38% of total billed charges,1446,40,,3.84,percent of total billed charges,40% of total billed charges,1016.94,2668,
"CLOSED TREATMENT OF METACARPAL FRACTURE; SINGLE; WITH MANIPULATION, EACH BONE",3900056,CDM,450,RC,26605,HCPCS,OUTPATIENT,,,620,372,,527,85,,421.6,Percent of total billed charges,85% of total billed charges,861.18,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,198.09,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,198.09,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,235.6,38,,497.952,percent of total billed charges,38% of total billed charges,248,40,,3.84,percent of total billed charges,40% of total billed charges,1017.94,2669,
"CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, WITH MANIPULATION;",3900057,CDM,450,RC,26700,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,243.94,35.15,,6.128,fee schedule,35.15% of LA custom fee schedule,221.73,31.95,,88.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,263.72,38,,497.952,percent of total billed charges,38% of total billed charges,221.73,31.95,,5.568,Fee Schedule,31.95% of LA custom fee schedule,1018.94,2670,
"CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION, BILATER",3900058,CDM,450,RC,25565,HCPCS,OUTPATIENT,,,1230,738,,1045.5,85,,836.4,Percent of total billed charges,85% of total billed charges,861.18,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,16.728,fee schedule,136.60% of BCBS custom fee schedule,392.99,31.95,,8.976,percent of total billed charges,31.95% of total billed charges,392.99,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,467.4,38,,242.288,percent of total billed charges,38% of total billed charges,492,40,,8.16,percent of total billed charges,40% of total billed charges,1019.94,2671,
"CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION, LEFT",3900059,CDM,450,RC,25565,HCPCS,OUTPATIENT,,,1230,738,LT,1045.5,85,,836.4,Percent of total billed charges,85% of total billed charges,861.18,136.6,,16.728,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,177.6,fee schedule,136.60% of BCBS custom fee schedule,392.99,31.95,,6.12,percent of total billed charges,31.95% of total billed charges,392.99,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,467.4,38,,242.288,percent of total billed charges,38% of total billed charges,492,40,,5.568,percent of total billed charges,40% of total billed charges,1020.94,2672,
"CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION, RIGHT",3900060,CDM,450,RC,25565,HCPCS,OUTPATIENT,,,1230,738,RT,1045.5,85,,836.4,Percent of total billed charges,85% of total billed charges,861.18,136.6,,177.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,177.6,fee schedule,136.60% of BCBS custom fee schedule,392.99,31.95,,6.128,percent of total billed charges,31.95% of total billed charges,392.99,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,467.4,38,,1403.872,percent of total billed charges,38% of total billed charges,492,40,,5.568,percent of total billed charges,40% of total billed charges,1021.94,2673,
"CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPIULATION, BILATERAL",3900061,CDM,450,RC,24655,HCPCS,OUTPATIENT,,,694,416.4,50,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,177.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,7.8,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,1403.872,percent of total billed charges,38% of total billed charges,277.6,40,,7.096,percent of total billed charges,40% of total billed charges,1022.94,2674,
"CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPIULATION, LEFT",3900062,CDM,450,RC,24655,HCPCS,OUTPATIENT,,,694,416.4,LT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,1403.872,percent of total billed charges,38% of total billed charges,277.6,40,,3.064,percent of total billed charges,40% of total billed charges,1023.94,2675,
"CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPIULATION, RIGHT",3900063,CDM,450,RC,24655,HCPCS,OUTPATIENT,,,694,416.4,RT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,6.128,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,1298.992,percent of total billed charges,38% of total billed charges,277.6,40,,5.568,percent of total billed charges,40% of total billed charges,1024.94,2676,
"CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANI",3900064,CDM,450,RC,24640,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,33.104,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,6.12,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,194.256,percent of total billed charges,38% of total billed charges,277.6,40,,5.568,percent of total billed charges,40% of total billed charges,1025.94,2677,
"CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANI",3900065,CDM,450,RC,24640,HCPCS,OUTPATIENT,,,694,416.4,LT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,33.104,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,13.944,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,10.848,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,34.96,percent of total billed charges,38% of total billed charges,277.6,40,,9.864,percent of total billed charges,40% of total billed charges,1026.94,2678,
"CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANI",3900066,CDM,450,RC,24640,HCPCS,OUTPATIENT,,,694,416.4,RT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,13.944,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,18.36,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,5.888,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,90.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,70.832,percent of total billed charges,38% of total billed charges,277.6,40,,5.352,percent of total billed charges,40% of total billed charges,1027.94,2679,
"CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION, BILATERAL",3900067,CDM,450,RC,25505,HCPCS,OUTPATIENT,,,1227,736.2,50,1042.95,85,,834.36,Percent of total billed charges,85% of total billed charges,861.18,136.6,,18.36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,28.184,fee schedule,136.60% of BCBS custom fee schedule,392.03,31.95,,6.128,percent of total billed charges,31.95% of total billed charges,392.03,31.95,,91.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,466.26,38,,79.648,percent of total billed charges,38% of total billed charges,490.8,40,,5.568,percent of total billed charges,40% of total billed charges,1028.94,2680,
"CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION, LEFT",3900068,CDM,450,RC,25505,HCPCS,OUTPATIENT,,,1227,736.2,LT,1042.95,85,,834.36,Percent of total billed charges,85% of total billed charges,861.18,136.6,,28.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,392.03,31.95,,6.12,percent of total billed charges,31.95% of total billed charges,392.03,31.95,,91.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,466.26,38,,121.904,percent of total billed charges,38% of total billed charges,490.8,40,,5.568,percent of total billed charges,40% of total billed charges,1029.94,2681,
"CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION, RIGHT",3900069,CDM,450,RC,25505,HCPCS,OUTPATIENT,,,1227,736.2,RT,1042.95,85,,834.36,Percent of total billed charges,85% of total billed charges,861.18,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,16.944,fee schedule,136.60% of BCBS custom fee schedule,392.03,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,392.03,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,466.26,38,,121.904,percent of total billed charges,38% of total billed charges,490.8,40,,5.344,percent of total billed charges,40% of total billed charges,1030.94,2682,
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION, WITH ANESTHESIA, BI",3900070,CDM,450,RC,23655,HCPCS,OUTPATIENT,,,4618,2770.8,,3925.3,85,,3140.24,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,16.944,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,16.944,fee schedule,136.60% of BCBS custom fee schedule,1475.45,31.95,,4.336,percent of total billed charges,31.95% of total billed charges,1475.45,31.95,,92.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1754.84,38,,121.904,percent of total billed charges,38% of total billed charges,1847.2,40,,3.944,percent of total billed charges,40% of total billed charges,1031.94,2683,
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION, WITH ANESTHESIA, LE",3900071,CDM,450,RC,23655,HCPCS,OUTPATIENT,,,4618,2770.8,LT,3925.3,85,,3140.24,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,16.944,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,24.592,fee schedule,136.60% of BCBS custom fee schedule,1475.45,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1475.45,31.95,,94.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1754.84,38,,119.472,percent of total billed charges,38% of total billed charges,1847.2,40,,3.064,percent of total billed charges,40% of total billed charges,1032.94,2684,
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION, WITH ANESTHESIA, RI",3900072,CDM,450,RC,23655,HCPCS,OUTPATIENT,,,4618,2770.8,RT,3925.3,85,,3140.24,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,24.592,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,16.12,fee schedule,136.60% of BCBS custom fee schedule,1475.45,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1475.45,31.95,,95.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1754.84,38,,119.472,percent of total billed charges,38% of total billed charges,1847.2,40,,3.064,percent of total billed charges,40% of total billed charges,1033.94,2685,
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION, WITHOUT ANESTHESIA,",3900073,CDM,450,RC,23650,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,16.12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,95.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,1394.144,percent of total billed charges,38% of total billed charges,277.6,40,,3.064,percent of total billed charges,40% of total billed charges,1034.94,2686,
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION, WITHOUT ANESTHESIA,",3900074,CDM,450,RC,23650,HCPCS,OUTPATIENT,,,694,416.4,LT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,11.032,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,866.704,percent of total billed charges,38% of total billed charges,277.6,40,,3.064,percent of total billed charges,40% of total billed charges,1035.94,2687,
"CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION, WITHOUT ANESTHESIA,",3900075,CDM,450,RC,23650,HCPCS,OUTPATIENT,,,694,416.4,RT,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,861.18,136.6,,11.032,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,96.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,1004.72,percent of total billed charges,38% of total billed charges,277.6,40,,3.064,percent of total billed charges,40% of total billed charges,1036.94,2688,
"CLOSED TREATMENT OF TEMPEROMANDIBULAR DISLOCATION, INITIAL OR SUBSEQUENT, BILATE",3900076,CDM,450,RC,21480,HCPCS,OUTPATIENT,,,336,201.6,50,285.6,85,,228.48,Percent of total billed charges,85% of total billed charges,520.43,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,520.43,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,107.35,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,107.35,31.95,,96.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.68,38,,1004.72,percent of total billed charges,38% of total billed charges,134.4,40,,3.064,percent of total billed charges,40% of total billed charges,1037.94,2689,
"CLOSED TREATMENT OF TEMPEROMANDIBULAR DISLOCATION, INITIAL OR SUBSEQUENT, LEFT",3900077,CDM,450,RC,21480,HCPCS,OUTPATIENT,,,336,201.6,LT,285.6,85,,228.48,Percent of total billed charges,85% of total billed charges,520.43,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,520.43,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,107.35,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,107.35,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.68,38,,1004.72,percent of total billed charges,38% of total billed charges,134.4,40,,3.064,percent of total billed charges,40% of total billed charges,1038.94,2690,
"CLOSED TREATMENT OF TEMPEROMANDIBULAR DISLOCATION, INITIAL OR SUBSEQUENT, RIGHT",3900078,CDM,450,RC,21480,HCPCS,OUTPATIENT,,,336,201.6,RT,285.6,85,,228.48,Percent of total billed charges,85% of total billed charges,520.43,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,520.43,136.6,,88.4,fee schedule,136.60% of BCBS custom fee schedule,107.35,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,107.35,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.68,38,,65.056,percent of total billed charges,38% of total billed charges,134.4,40,,3.84,percent of total billed charges,40% of total billed charges,1039.94,2691,
"CLOSED TREATMENT PATELLAR DISLOCATION, BILATERAL",3900079,CDM,450,RC,27560,HCPCS,OUTPATIENT,,,433,259.8,50,368.05,85,,294.44,Percent of total billed charges,85% of total billed charges,861.18,136.6,,88.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,27,fee schedule,136.60% of BCBS custom fee schedule,138.34,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,138.34,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,164.54,38,,119.472,percent of total billed charges,38% of total billed charges,173.2,40,,3.84,percent of total billed charges,40% of total billed charges,1040.94,2692,
"CLOSED TREATMENT PATELLAR DISLOCATION, LEFT",3900080,CDM,450,RC,27560,HCPCS,OUTPATIENT,,,433,259.8,LT,368.05,85,,294.44,Percent of total billed charges,85% of total billed charges,861.18,136.6,,27,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,138.34,31.95,,6.848,percent of total billed charges,31.95% of total billed charges,138.34,31.95,,6.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,164.54,38,,241.984,percent of total billed charges,38% of total billed charges,173.2,40,,8.576,percent of total billed charges,40% of total billed charges,1041.94,2693,
"CLOSED TREATMENT PATELLAR DISLOCATION, RIGHT",3900081,CDM,450,RC,27560,HCPCS,OUTPATIENT,,,433,259.8,RT,368.05,85,,294.44,Percent of total billed charges,85% of total billed charges,861.18,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,138.34,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,138.34,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,164.54,38,,497.952,percent of total billed charges,38% of total billed charges,173.2,40,,12.16,percent of total billed charges,40% of total billed charges,1042.94,2694,
"CLOSED TREATMENT TIBIA FRACTURE WITH TRACTION, BILATERAL",3900082,CDM,450,RC,27825,HCPCS,OUTPATIENT,,,5009,3005.4,,4257.65,85,,3406.12,Percent of total billed charges,85% of total billed charges,861.18,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,7,fee schedule,136.60% of BCBS custom fee schedule,1600.38,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,1600.38,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1903.42,38,,497.952,percent of total billed charges,38% of total billed charges,2003.6,40,,6.4,percent of total billed charges,40% of total billed charges,1043.94,2695,
"CLOSED TREATMENT TIBIA FRACTURE WITH TRACTION, LEFT",3900083,CDM,450,RC,27825,HCPCS,OUTPATIENT,,,5009,3005.4,,4257.65,85,,3406.12,Percent of total billed charges,85% of total billed charges,861.18,136.6,,7,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,1600.38,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,1600.38,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1903.42,38,,169.936,percent of total billed charges,38% of total billed charges,2003.6,40,,14.72,percent of total billed charges,40% of total billed charges,1044.94,2696,
"CLOSED TREATMENT TIBIA FRACTURE WITH TRACTION, RIGHT",3900084,CDM,450,RC,27825,HCPCS,OUTPATIENT,,,5009,3005.4,,4257.65,85,,3406.12,Percent of total billed charges,85% of total billed charges,861.18,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,78.4,fee schedule,136.60% of BCBS custom fee schedule,1600.38,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1600.38,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1903.42,38,,198.816,percent of total billed charges,38% of total billed charges,2003.6,40,,1.92,percent of total billed charges,40% of total billed charges,1045.94,2697,
"CLOSED TREATMENT TIBIAL SHAFT W/O MANIPULATION, BILATERAL",3900085,CDM,450,RC,27750,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,78.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,497.952,percent of total billed charges,38% of total billed charges,277.6,40,,1.28,percent of total billed charges,40% of total billed charges,1046.94,2698,
"CLOSED TREATMENT TIBIAL SHAFT W/O MANIPULATION, LEFT",3900086,CDM,450,RC,27750,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,198.816,percent of total billed charges,38% of total billed charges,277.6,40,,8,percent of total billed charges,40% of total billed charges,1047.94,2699,
"CLOSED TREATMENT TIBIAL SHAFT W/O MANIPULATION, RIGHT",3900087,CDM,450,RC,27750,HCPCS,OUTPATIENT,,,694,416.4,,589.9,85,,471.92,Percent of total billed charges,85% of total billed charges,430.58,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,33.6,fee schedule,136.60% of BCBS custom fee schedule,221.73,31.95,,23.768,percent of total billed charges,31.95% of total billed charges,221.73,31.95,,23.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,263.72,38,,241.984,percent of total billed charges,38% of total billed charges,277.6,40,,29.76,percent of total billed charges,40% of total billed charges,1048.94,2700,
CONTROL NASAL HEMM ANT SIMPLE,3900088,CDM,450,RC,30901,HCPCS,OUTPATIENT,,,335,201,,284.75,85,,227.8,Percent of total billed charges,85% of total billed charges,306.45,136.6,,33.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,306.45,136.6,,852,fee schedule,136.60% of BCBS custom fee schedule,107.03,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,107.03,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.3,38,,497.952,percent of total billed charges,38% of total billed charges,134,40,,29.12,percent of total billed charges,40% of total billed charges,1049.94,2701,
CTRL NSL HEMRRG PST NASAL PACKS/CAUTERY 1ST,3900089,CDM,450,RC,30905,HCPCS,OUTPATIENT,,,337,202.2,,286.45,85,,229.16,Percent of total billed charges,85% of total billed charges,306.45,136.6,,852,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,306.45,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,107.67,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,107.67,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.06,38,,103.056,percent of total billed charges,38% of total billed charges,134.8,40,,29.12,percent of total billed charges,40% of total billed charges,1050.94,2702,
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX,3900090,CDM,450,RC,30903,HCPCS,OUTPATIENT,,,335,201,,284.75,85,,227.8,Percent of total billed charges,85% of total billed charges,306.45,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,306.45,136.6,,876.928,fee schedule,136.60% of BCBS custom fee schedule,107.03,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,107.03,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.3,38,,497.952,percent of total billed charges,38% of total billed charges,134,40,,29.12,percent of total billed charges,40% of total billed charges,1051.94,2703,
DEBRIDEMENT SUBCUTANEOUS TISSUE EACH ADDITIONAL 20 SQ CM,3900091,CDM,450,RC,11045,HCPCS,OUTPATIENT,,,550,330,,467.5,85,,374,Percent of total billed charges,85% of total billed charges,0.01,136.6,,876.928,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,438.464,fee schedule,136.60% of BCBS custom fee schedule,193.33,35.15,,18.912,fee schedule,35.15% of LA custom fee schedule,175.73,31.95,,18.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,209,38,,70.528,percent of total billed charges,38% of total billed charges,175.73,31.95,,23.68,Fee Schedule,31.95% of LA custom fee schedule,1052.94,2704,
DRAIN ABSCESS/CY/HEM DENTAL,3900092,CDM,450,RC,41800,HCPCS,OUTPATIENT,,,648,388.8,,550.8,85,,440.64,Percent of total billed charges,85% of total billed charges,520.43,136.6,,438.464,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,520.43,136.6,,169.184,fee schedule,136.60% of BCBS custom fee schedule,207.04,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,207.04,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,246.24,38,,70.528,percent of total billed charges,38% of total billed charges,259.2,40,,10.56,percent of total billed charges,40% of total billed charges,1053.94,2705,
"DRAINAGE ABSCESS,CYST VES-MOUT",3900093,CDM,450,RC,40800,HCPCS,OUTPATIENT,,,650,390,,552.5,85,,442,Percent of total billed charges,85% of total billed charges,520.43,136.6,,169.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,520.43,136.6,,59.8,fee schedule,136.60% of BCBS custom fee schedule,207.68,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,207.68,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,247,38,,70.528,percent of total billed charges,38% of total billed charges,260,40,,12.16,percent of total billed charges,40% of total billed charges,1054.94,2706,
"DRESSING AND/OR DEBRIDEMENT OF PARTIAL=THICKNESS BURNS, INITIAL OR SUBSEQUENT; M",3900094,CDM,450,RC,16025,HCPCS,OUTPATIENT,,,590,354,,501.5,85,,401.2,Percent of total billed charges,85% of total billed charges,295,50,,59.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,295,50,,161.288,percent of total billed charges,50% of total billed charges,188.51,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,188.51,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,224.2,38,,51.072,percent of total billed charges,38% of total billed charges,236,40,,5.12,percent of total billed charges,40% of total billed charges,1055.94,2707,
"DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT,;",3900095,CDM,450,RC,16020,HCPCS,OUTPATIENT,,,590,354,,501.5,85,,401.2,Percent of total billed charges,85% of total billed charges,495.68,136.6,,161.288,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,50.272,fee schedule,136.60% of BCBS custom fee schedule,188.51,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,188.51,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,224.2,38,,121.6,percent of total billed charges,38% of total billed charges,236,40,,28.8,percent of total billed charges,40% of total billed charges,1056.94,2708,
TREAT ELBOW DISLOCATION,3900096,CDM,450,RC,24600,HCPCS,OUTPATIENT,,,860,516,,731,85,,584.8,Percent of total billed charges,85% of total billed charges,861.18,136.6,,50.272,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,47.304,fee schedule,136.60% of BCBS custom fee schedule,274.77,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,274.77,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,326.8,38,,51.072,percent of total billed charges,38% of total billed charges,344,40,,28.8,percent of total billed charges,40% of total billed charges,1057.94,2709,
ER DERMABOND CLOSURE,3900097,CDM,450,RC,G0168,HCPCS,OUTPATIENT,,,106,63.6,,90.1,85,,72.08,Percent of total billed charges,85% of total billed charges,53,50,,47.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53,50,,49.632,percent of total billed charges,50% of total billed charges,37.26,35.15,,17.92,percent of total billed charges,35.15% of total billed charges,958.5,31.95,,17.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.28,38,,83.904,percent of total billed charges,38% of total billed charges,33.87,31.95,,22.432,percent of total billed charges,31.95% of total billed charges,1058.94,2710,
99281 ED VISIT Level 1,3900098,CDM,450,RC,99281,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,249.91,136.6,,49.632,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.91,136.6,,70.696,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,3.576,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,150,38,,51.072,percent of total billed charges,38% of total billed charges,73.49,31.95,,4.48,Fee Schedule,31.95% of LA custom fee schedule,1059.94,2711,
99281 - ED Level 1 No Phys Required,3900098,CDM,450,RC,99281,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,249.91,136.6,,70.696,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.91,136.6,,74.528,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,182.784,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,9.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,150,38,,83.904,percent of total billed charges,38% of total billed charges,73.49,31.95,,166.144,Fee Schedule,31.95% of LA custom fee schedule,1060.94,2712,
99281 - ED Level 1,3900098,CDM,450,RC,99281,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,249.91,136.6,,74.528,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.91,136.6,,59.776,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,1.408,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,9.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,150,38,,51.072,percent of total billed charges,38% of total billed charges,73.49,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,1061.94,2713,
99282 ED Level 2,3900099,CDM,450,RC,99282,HCPCS,OUTPATIENT,,,445,267,,378.25,85,,302.6,Percent of total billed charges,85% of total billed charges,249.91,136.6,,59.776,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.91,136.6,,67,fee schedule,136.60% of BCBS custom fee schedule,156.42,35.15,,0.256,fee schedule,35.15% of LA custom fee schedule,142.18,31.95,,0.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,207,38,,91.2,percent of total billed charges,38% of total billed charges,142.18,31.95,,0.32,Fee Schedule,31.95% of LA custom fee schedule,1062.94,2714,
99282 - ED Level 2,3900099,CDM,450,RC,99282,HCPCS,OUTPATIENT,,,445,267,,378.25,85,,302.6,Percent of total billed charges,85% of total billed charges,249.91,136.6,,67,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.91,136.6,,67,fee schedule,136.60% of BCBS custom fee schedule,156.42,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,142.18,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,207,38,,47.12,percent of total billed charges,38% of total billed charges,142.18,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,1063.94,2715,
99282 - ED Level 2,3900099,CDM,450,RC,99282,HCPCS,OUTPATIENT,,,445,267,,378.25,85,,302.6,Percent of total billed charges,85% of total billed charges,249.91,136.6,,67,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.91,136.6,,51.36,fee schedule,136.60% of BCBS custom fee schedule,156.42,35.15,,4.888,fee schedule,35.15% of LA custom fee schedule,142.18,31.95,,4.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,207,38,,106.4,percent of total billed charges,38% of total billed charges,142.18,31.95,,6.12,Fee Schedule,31.95% of LA custom fee schedule,1064.94,2716,
99283 ED VISIT Level 3,3900103,CDM,450,RC,99283,HCPCS,OUTPATIENT,,,730,438,,620.5,85,,496.4,Percent of total billed charges,85% of total billed charges,437.49,136.6,,51.36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,437.49,136.6,,51.36,fee schedule,136.60% of BCBS custom fee schedule,256.6,35.15,,3.52,fee schedule,35.15% of LA custom fee schedule,233.24,31.95,,3.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,475,38,,195.168,percent of total billed charges,38% of total billed charges,233.24,31.95,,4.4,Fee Schedule,31.95% of LA custom fee schedule,1065.94,2717,
99283 - ED Level 3,3900103,CDM,450,RC,99283,HCPCS,OUTPATIENT,,,730,438,,620.5,85,,496.4,Percent of total billed charges,85% of total billed charges,437.49,136.6,,51.36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,437.49,136.6,,28.024,fee schedule,136.60% of BCBS custom fee schedule,256.6,35.15,,30.16,fee schedule,35.15% of LA custom fee schedule,233.24,31.95,,30.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,475,38,,195.168,percent of total billed charges,38% of total billed charges,233.24,31.95,,37.76,Fee Schedule,31.95% of LA custom fee schedule,1066.94,2718,
99283 - ED Level 3,3900103,CDM,450,RC,99283,HCPCS,OUTPATIENT,,,730,438,,620.5,85,,496.4,Percent of total billed charges,85% of total billed charges,437.49,136.6,,28.024,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,437.49,136.6,,76.992,fee schedule,136.60% of BCBS custom fee schedule,256.6,35.15,,0.256,fee schedule,35.15% of LA custom fee schedule,233.24,31.95,,0.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,475,38,,51.072,percent of total billed charges,38% of total billed charges,233.24,31.95,,0.32,Fee Schedule,31.95% of LA custom fee schedule,1067.94,2719,
99284 ED Visit Level 4,3900104,CDM,450,RC,99284,HCPCS,OUTPATIENT,,,1340,804,,1139,85,,911.2,Percent of total billed charges,85% of total billed charges,761.27,136.6,,76.992,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,761.27,136.6,,37.696,fee schedule,136.60% of BCBS custom fee schedule,471.01,35.15,,17.04,fee schedule,35.15% of LA custom fee schedule,428.13,31.95,,17.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,940,38,,91.2,percent of total billed charges,38% of total billed charges,428.13,31.95,,21.336,Fee Schedule,31.95% of LA custom fee schedule,1068.94,2720,
99284 - ED Level 4,3900104,CDM,450,RC,99284,HCPCS,OUTPATIENT,,,1340,804,,1139,85,,911.2,Percent of total billed charges,85% of total billed charges,761.27,136.6,,37.696,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,761.27,136.6,,38.44,fee schedule,136.60% of BCBS custom fee schedule,471.01,35.15,,3.576,fee schedule,35.15% of LA custom fee schedule,428.13,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,940,38,,51.072,percent of total billed charges,38% of total billed charges,428.13,31.95,,4.48,Fee Schedule,31.95% of LA custom fee schedule,1069.94,2721,
99284 - ED Level 4,3900104,CDM,450,RC,99284,HCPCS,OUTPATIENT,,,1340,804,,1139,85,,911.2,Percent of total billed charges,85% of total billed charges,761.27,136.6,,38.44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,761.27,136.6,,67,fee schedule,136.60% of BCBS custom fee schedule,471.01,35.15,,107.384,fee schedule,35.15% of LA custom fee schedule,428.13,31.95,,107.384,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,940,38,,83.904,percent of total billed charges,38% of total billed charges,428.13,31.95,,134.44,Fee Schedule,31.95% of LA custom fee schedule,1070.94,2722,
99285 ED Visit Level 5,3900105,CDM,450,RC,99285,HCPCS,OUTPATIENT,,,1980,1188,,1683,85,,1346.4,Percent of total billed charges,85% of total billed charges,761.27,136.6,,67,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,761.27,136.6,,229.152,fee schedule,136.60% of BCBS custom fee schedule,695.97,35.15,,3.832,fee schedule,35.15% of LA custom fee schedule,632.61,31.95,,3.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1742,38,,63.84,percent of total billed charges,38% of total billed charges,632.61,31.95,,4.8,Fee Schedule,31.95% of LA custom fee schedule,1071.94,2723,
99285 - ED Level 5,3900105,CDM,450,RC,99285,HCPCS,OUTPATIENT,,,1980,1188,,1683,85,,1346.4,Percent of total billed charges,85% of total billed charges,761.27,136.6,,229.152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,761.27,136.6,,229.152,fee schedule,136.60% of BCBS custom fee schedule,695.97,35.15,,107.384,fee schedule,35.15% of LA custom fee schedule,632.61,31.95,,107.384,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1742,38,,129.2,percent of total billed charges,38% of total billed charges,632.61,31.95,,134.44,Fee Schedule,31.95% of LA custom fee schedule,1072.94,2724,
99285 - ED Level 5,3900105,CDM,450,RC,99285,HCPCS,OUTPATIENT,,,1980,1188,,1683,85,,1346.4,Percent of total billed charges,85% of total billed charges,761.27,136.6,,229.152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,761.27,136.6,,5.552,fee schedule,136.60% of BCBS custom fee schedule,695.97,35.15,,86.264,fee schedule,35.15% of LA custom fee schedule,632.61,31.95,,86.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1742,38,,70.528,percent of total billed charges,38% of total billed charges,632.61,31.95,,108,Fee Schedule,31.95% of LA custom fee schedule,1073.94,2725,
EVACUATION SUBUNGUAL HEMATOMA,3900106,CDM,450,RC,11740,HCPCS,OUTPATIENT,,,243,145.8,,206.55,85,,165.24,Percent of total billed charges,85% of total billed charges,188.07,136.6,,5.552,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,7.096,fee schedule,136.60% of BCBS custom fee schedule,85.41,35.15,,13.6,fee schedule,35.15% of LA custom fee schedule,77.64,31.95,,13.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,92.34,38,,70.528,percent of total billed charges,38% of total billed charges,77.64,31.95,,17.032,Fee Schedule,31.95% of LA custom fee schedule,1074.94,2726,
"FRACTURE OF FEMUR WITH MANIPULATION AND TREATMENT, BILATERAL",3900107,CDM,450,RC,27232,HCPCS,OUTPATIENT,,,2975,1785,50,2528.75,85,,2023,Percent of total billed charges,85% of total billed charges,6093.99,136.6,,7.096,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6093.99,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,1045.71,35.15,,51.12,percent of total billed charges,35.15% of total billed charges,958.5,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1130.5,38,,70.528,percent of total billed charges,38% of total billed charges,950.51,31.95,,64,percent of total billed charges,31.95% of total billed charges,1075.94,2727,
"FRACTURE OF FEMUR WITH MANIPULATION AND TREATMENT, LEFT",3900108,CDM,450,RC,27232,HCPCS,OUTPATIENT,,,2975,1785,LT,2528.75,85,,2023,Percent of total billed charges,85% of total billed charges,6093.99,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6093.99,136.6,,5.624,fee schedule,136.60% of BCBS custom fee schedule,1045.71,35.15,,2.56,percent of total billed charges,35.15% of total billed charges,958.5,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1130.5,38,,70.528,percent of total billed charges,38% of total billed charges,950.51,31.95,,3.208,percent of total billed charges,31.95% of total billed charges,1076.94,2728,
"FRACTURE OF FEMUR WITH MANIPULATION AND TREATMENT, RIGHT",3900109,CDM,450,RC,27232,HCPCS,OUTPATIENT,,,2975,1785,RT,2528.75,85,,2023,Percent of total billed charges,85% of total billed charges,6093.99,136.6,,5.624,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,6093.99,136.6,,5.064,fee schedule,136.60% of BCBS custom fee schedule,1045.71,35.15,,2.56,percent of total billed charges,35.15% of total billed charges,958.5,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1130.5,38,,70.528,percent of total billed charges,38% of total billed charges,950.51,31.95,,3.208,percent of total billed charges,31.95% of total billed charges,1077.94,2729,
INCISION AND DRAINAGE ABSCESS RETRO/PARAPHARYNG,3900110,CDM,450,RC,42720,HCPCS,OUTPATIENT,,,5067,3040.2,,4306.95,85,,3445.56,Percent of total billed charges,85% of total billed charges,4024.02,136.6,,5.064,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4024.02,136.6,,15.032,fee schedule,136.60% of BCBS custom fee schedule,1618.91,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,1618.91,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1925.46,38,,70.528,percent of total billed charges,38% of total billed charges,2026.8,40,,3.208,percent of total billed charges,40% of total billed charges,1078.94,2730,
"INITIAL TREATMENT, FIRST-DEGREE BURN WHEN NO MORE THAN LOCAL TREATMENT IS REQUIR",3900111,CDM,450,RC,16000,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,112.5,50,,15.032,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,112.5,50,,5.768,percent of total billed charges,50% of total billed charges,79.09,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,71.89,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,85.5,38,,70.528,percent of total billed charges,38% of total billed charges,71.89,31.95,,3.208,Fee Schedule,31.95% of LA custom fee schedule,1079.94,2731,
INJECTION ANETHESIA AGENT BRACHIAL PLEXUS,3900112,CDM,450,RC,64415,HCPCS,OUTPATIENT,,,1489,893.4,,1265.65,85,,1012.52,Percent of total billed charges,85% of total billed charges,567.44,136.6,,5.768,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,2.936,fee schedule,136.60% of BCBS custom fee schedule,475.74,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,475.74,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,565.82,38,,70.528,percent of total billed charges,38% of total billed charges,595.6,40,,3.208,percent of total billed charges,40% of total billed charges,1080.94,2732,
INJECTION ANETHESIA AGENT PERIPHERAL,3900113,CDM,450,RC,64450,HCPCS,OUTPATIENT,,,1416,849.6,,1203.6,85,,962.88,Percent of total billed charges,85% of total billed charges,567.44,136.6,,2.936,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,452.41,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,452.41,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,538.08,38,,70.528,percent of total billed charges,38% of total billed charges,566.4,40,,3.208,percent of total billed charges,40% of total billed charges,1081.94,2733,
INJECTION ANETHESIA AGENT SCIATIC NERVE,3900114,CDM,450,RC,64445,HCPCS,OUTPATIENT,,,2689,1613.4,,2285.65,85,,1828.52,Percent of total billed charges,85% of total billed charges,567.44,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,493.336,fee schedule,136.60% of BCBS custom fee schedule,945.18,35.15,,60.32,fee schedule,35.15% of LA custom fee schedule,859.14,31.95,,60.32,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1021.82,38,,63.84,percent of total billed charges,38% of total billed charges,859.14,31.95,,75.52,Fee Schedule,31.95% of LA custom fee schedule,1082.94,2734,
INJECTION ANETHESIA AGENT TRIGEMINAL,3900115,CDM,450,RC,64400,HCPCS,OUTPATIENT,,,845,507,,718.25,85,,574.6,Percent of total billed charges,85% of total billed charges,567.44,136.6,,493.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,0.568,fee schedule,136.60% of BCBS custom fee schedule,297.02,35.15,,12.016,fee schedule,35.15% of LA custom fee schedule,269.98,31.95,,12.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,321.1,38,,63.84,percent of total billed charges,38% of total billed charges,269.98,31.95,,15.04,Fee Schedule,31.95% of LA custom fee schedule,1083.94,2735,
"96374 INJECTION, SINGLE/INITIAL DRUG CHARGE",3900116,CDM,260,RC,96374,HCPCS,OUTPATIENT,,,424,254.4,59,360.4,85,,288.32,Percent of total billed charges,85% of total billed charges,161.95,136.6,,0.568,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,0.568,fee schedule,136.60% of BCBS custom fee schedule,149.04,35.15,,12.016,percent of total billed charges,35.15% of total billed charges,966.17,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,63.84,case rate,pays based on per visit rate,135.47,31.95,,15.04,percent of total billed charges,31.95% of total billed charges,1084.94,2736,
"96374 - IV Injection, single/initial",3900116,CDM,260,RC,96374,HCPCS,OUTPATIENT,,,424,254.4,59,360.4,85,,288.32,Percent of total billed charges,85% of total billed charges,161.95,136.6,,0.568,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,149.04,35.15,,12.016,percent of total billed charges,35.15% of total billed charges,966.17,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,70.528,case rate,pays based on per visit rate,135.47,31.95,,15.04,percent of total billed charges,31.95% of total billed charges,1085.94,2737,
"96374 IV Injection, single/initial",3900116,CDM,260,RC,96374,HCPCS,OUTPATIENT,,,424,254.4,59,360.4,85,,288.32,Percent of total billed charges,85% of total billed charges,161.95,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,41.248,fee schedule,136.60% of BCBS custom fee schedule,149.04,35.15,,8.432,percent of total billed charges,35.15% of total billed charges,985.66,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,70.528,case rate,pays based on per visit rate,135.47,31.95,,10.56,percent of total billed charges,31.95% of total billed charges,1086.94,2738,
INJECTION TX/PRO/DX INJ SAME DRUG ADDON,3900117,CDM,260,RC,96376,HCPCS,OUTPATIENT,,,10,6,59,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,1.78,136.6,,41.248,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,8.672,fee schedule,136.60% of BCBS custom fee schedule,3.52,35.15,,12.016,percent of total billed charges,35.15% of total billed charges,987.26,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,70.528,case rate,pays based on per visit rate,3.2,31.95,,15.04,percent of total billed charges,31.95% of total billed charges,1087.94,2739,
"96375 INJECTION, ADD NEW DRUG CHARGE",3900118,CDM,260,RC,96375,HCPCS,OUTPATIENT,,,176,105.6,59,149.6,85,,119.68,Percent of total billed charges,85% of total billed charges,88.18,136.6,,8.672,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,88.18,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,61.86,35.15,,21.472,percent of total billed charges,35.15% of total billed charges,1000.04,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,70.528,case rate,pays based on per visit rate,56.23,31.95,,26.88,percent of total billed charges,31.95% of total billed charges,1088.94,2740,
"96375 - IV Injection, add new drug",3900118,CDM,260,RC,96375,HCPCS,OUTPATIENT,,,176,105.6,59,149.6,85,,119.68,Percent of total billed charges,85% of total billed charges,88.18,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,88.18,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,61.86,35.15,,310.552,percent of total billed charges,35.15% of total billed charges,1004.83,31.95,,310.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,223.44,case rate,pays based on per visit rate,56.23,31.95,,388.8,percent of total billed charges,31.95% of total billed charges,1089.94,2741,
"96375 IV Injection, add new drug",3900118,CDM,260,RC,96375,HCPCS,OUTPATIENT,,,176,105.6,59,149.6,85,,119.68,Percent of total billed charges,85% of total billed charges,88.18,136.6,,16.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,88.18,136.6,,5.752,fee schedule,136.60% of BCBS custom fee schedule,61.86,35.15,,16.872,percent of total billed charges,35.15% of total billed charges,1019.21,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,663.024,case rate,pays based on per visit rate,56.23,31.95,,21.12,percent of total billed charges,31.95% of total billed charges,1090.94,2742,
"96373 INJECTION, INTRA-ARTERIAL DRUG CHARGE",3900119,CDM,260,RC,96373,HCPCS,OUTPATIENT,,,424,254.4,59,360.4,85,,288.32,Percent of total billed charges,85% of total billed charges,161.95,136.6,,5.752,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,5.752,fee schedule,136.60% of BCBS custom fee schedule,149.04,35.15,,12.016,percent of total billed charges,35.15% of total billed charges,1038.38,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,466.032,case rate,pays based on per visit rate,135.47,31.95,,15.04,percent of total billed charges,31.95% of total billed charges,1091.94,2743,
96373 - Intra-Arterial injection,3900119,CDM,260,RC,96373,HCPCS,OUTPATIENT,,,424,254.4,59,360.4,85,,288.32,Percent of total billed charges,85% of total billed charges,161.95,136.6,,5.752,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,6.472,fee schedule,136.60% of BCBS custom fee schedule,149.04,35.15,,258.792,percent of total billed charges,35.15% of total billed charges,1038.38,31.95,,258.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,1210.528,case rate,pays based on per visit rate,135.47,31.95,,324,percent of total billed charges,31.95% of total billed charges,1092.94,2744,
96373 Intra-Arterial injection,3900119,CDM,260,RC,96373,HCPCS,OUTPATIENT,,,424,254.4,59,360.4,85,,288.32,Percent of total billed charges,85% of total billed charges,161.95,136.6,,6.472,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,161.95,136.6,,5.056,fee schedule,136.60% of BCBS custom fee schedule,149.04,35.15,,1.992,percent of total billed charges,35.15% of total billed charges,1044.13,31.95,,1.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,1210.528,case rate,pays based on per visit rate,135.47,31.95,,2.496,percent of total billed charges,31.95% of total billed charges,1093.94,2745,
"96372 INJECTION, SUBQ/IM CHARGE",3900120,CDM,260,RC,96372,HCPCS,OUTPATIENT,,,176,105.6,59,149.6,85,,119.68,Percent of total billed charges,85% of total billed charges,78.94,136.6,,5.056,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.94,136.6,,5.336,fee schedule,136.60% of BCBS custom fee schedule,61.86,35.15,,2.12,percent of total billed charges,35.15% of total billed charges,1044.13,31.95,,2.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,1210.528,case rate,pays based on per visit rate,56.23,31.95,,2.648,percent of total billed charges,31.95% of total billed charges,1094.94,2746,
96372 - Subq/IM Injection,3900120,CDM,260,RC,96372,HCPCS,OUTPATIENT,,,176,105.6,59,149.6,85,,119.68,Percent of total billed charges,85% of total billed charges,78.94,136.6,,5.336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.94,136.6,,6.952,fee schedule,136.60% of BCBS custom fee schedule,61.86,35.15,,122.688,percent of total billed charges,35.15% of total billed charges,1044.13,31.95,,122.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,575.168,case rate,pays based on per visit rate,56.23,31.95,,153.6,percent of total billed charges,31.95% of total billed charges,1095.94,2747,
96372 Subq/IM Injection,3900120,CDM,260,RC,96372,HCPCS,OUTPATIENT,,,176,105.6,59,149.6,85,,119.68,Percent of total billed charges,85% of total billed charges,78.94,136.6,,6.952,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.94,136.6,,8.184,fee schedule,136.60% of BCBS custom fee schedule,61.86,35.15,,10.224,percent of total billed charges,35.15% of total billed charges,1044.13,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,60.8,case rate,pays based on per visit rate,56.23,31.95,,12.8,percent of total billed charges,31.95% of total billed charges,1096.94,2748,
INSERT/REPLACE TEMP SIN CHAMB CARD,3900121,CDM,450,RC,33210,HCPCS,OUTPATIENT,,,18408,11044.8,,15646.8,85,,12517.44,Percent of total billed charges,85% of total billed charges,8557.88,136.6,,8.184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8557.88,136.6,,440,fee schedule,136.60% of BCBS custom fee schedule,6470.41,35.15,,20.448,fee schedule,35.15% of LA custom fee schedule,5881.36,31.95,,20.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,6995.04,38,,1600,percent of total billed charges,38% of total billed charges,5881.36,31.95,,25.6,Fee Schedule,31.95% of LA custom fee schedule,1097.94,2749,
INTRAOSSEOUS NEEDLE PLACEMENT,3900122,CDM,450,RC,36680,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,234.21,136.6,,440,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,234.21,136.6,,1.152,fee schedule,136.60% of BCBS custom fee schedule,56.24,35.15,,4.344,fee schedule,35.15% of LA custom fee schedule,51.12,31.95,,4.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.8,38,,1600,percent of total billed charges,38% of total billed charges,51.12,31.95,,5.44,Fee Schedule,31.95% of LA custom fee schedule,1098.94,2750,
DRAINAGE FINGER ABSCESS SIMPLE,3900123,CDM,450,RC,26010,HCPCS,OUTPATIENT,,,530,318,,450.5,85,,360.4,Percent of total billed charges,85% of total billed charges,378,136.6,,1.152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378,136.6,,1.624,fee schedule,136.60% of BCBS custom fee schedule,186.3,35.15,,0.512,fee schedule,35.15% of LA custom fee schedule,169.34,31.95,,0.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,201.4,38,,99.712,percent of total billed charges,38% of total billed charges,169.34,31.95,,0.64,Fee Schedule,31.95% of LA custom fee schedule,1099.94,2751,
"Repair interm, wounds of face, ears, eyelids, nose, lips, mucous membranes; 12.6",3900124,CDM,521,RC,12055,HCPCS,OUTPATIENT,,,575,345,,488.75,85,,391,Percent of total billed charges,85% of total billed charges,287.5,50,,1.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,287.5,50,,4.704,percent of total billed charges,50% of total billed charges,183.71,31.95,,31.6,percent of total billed charges,31.95% of total billed charges,183.71,31.95,,31.6,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,218.5,38,,99.712,percent of total billed charges,38% of total billed charges,230,40,,39.568,percent of total billed charges,40% of total billed charges,1100.94,2752,
LAYER CLOS OF WNDS OF FACE EARS EYE NOSE LIPS A/O MUC MEMB 12.6 CM TO 20 CM,3900124,CDM,450,RC,12055,HCPCS,OUTPATIENT,,,575,345,,488.75,85,,391,Percent of total billed charges,85% of total billed charges,287.5,50,,4.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,287.5,50,,114,percent of total billed charges,50% of total billed charges,183.71,31.95,,14.56,percent of total billed charges,31.95% of total billed charges,183.71,31.95,,14.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,218.5,38,,1246.4,percent of total billed charges,38% of total billed charges,230,40,,18.224,percent of total billed charges,40% of total billed charges,1101.94,2753,
"Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous Membrane 2.5 cm",3900125,CDM,521,RC,12051,HCPCS,OUTPATIENT,,,654,392.4,,555.9,85,,444.72,Percent of total billed charges,85% of total billed charges,948.82,136.6,,114,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,208.95,31.95,,138.888,percent of total billed charges,31.95% of total billed charges,208.95,31.95,,138.888,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,248.52,38,,224.96,percent of total billed charges,38% of total billed charges,261.6,40,,173.88,percent of total billed charges,40% of total billed charges,1102.94,2754,
LAYER CLOS OF WNDS OF FACE EARS EYE NOSE LIPS A/O MUC MEMB 2.5 CM OR LESS,3900125,CDM,450,RC,12051,HCPCS,OUTPATIENT,,,654,392.4,,555.9,85,,444.72,Percent of total billed charges,85% of total billed charges,948.82,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,208.95,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,208.95,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,248.52,38,,224.96,percent of total billed charges,38% of total billed charges,261.6,40,,5.76,percent of total billed charges,40% of total billed charges,1103.94,2755,
"Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous Membrane 2.6 cm",3900126,CDM,521,RC,12052,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,948.82,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,120,fee schedule,136.60% of BCBS custom fee schedule,254.64,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,302.86,38,,1197.76,percent of total billed charges,38% of total billed charges,318.8,40,,28.16,percent of total billed charges,40% of total billed charges,1104.94,2756,
LAYER CLOS OF WNDS OF FACE EARS EYE NOSE LIPS A/O MUC MEMB 2.6 CM TO 5.O CM,3900126,CDM,450,RC,12052,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,948.82,136.6,,120,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,476,fee schedule,136.60% of BCBS custom fee schedule,254.64,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,188.48,percent of total billed charges,38% of total billed charges,318.8,40,,28.16,percent of total billed charges,40% of total billed charges,1105.94,2757,
"Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous Membrane 5.1 cm",3900127,CDM,521,RC,12053,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,398.5,50,,476,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398.5,50,,740,percent of total billed charges,50% of total billed charges,254.64,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,302.86,38,,152,percent of total billed charges,38% of total billed charges,318.8,40,,26.88,percent of total billed charges,40% of total billed charges,1106.94,2758,
LAYER CLOS OF WNDS OF FACE EARS EYE NOSE LIPS A/O MUC MEMB 5.1 CM TO 7.5 CM,3900127,CDM,450,RC,12053,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,398.5,50,,740,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398.5,50,,616,percent of total billed charges,50% of total billed charges,254.64,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,121.6,percent of total billed charges,38% of total billed charges,318.8,40,,26.88,percent of total billed charges,40% of total billed charges,1107.94,2759,
"Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous Membrane 7.6 cm",3900128,CDM,521,RC,12054,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,398.5,50,,616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398.5,50,,133.2,percent of total billed charges,50% of total billed charges,254.64,31.95,,8.224,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,302.86,38,,91.2,percent of total billed charges,38% of total billed charges,318.8,40,,7.48,percent of total billed charges,40% of total billed charges,1108.94,2760,
LAYER CLOS OF WNDS OF FACE EARS EYEL NOSE LIPS A/O MUC MEMB 7.6 CM TO 12.5 CM,3900128,CDM,450,RC,12054,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,398.5,50,,133.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398.5,50,,644,percent of total billed charges,50% of total billed charges,254.64,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,6007.04,percent of total billed charges,38% of total billed charges,318.8,40,,5.76,percent of total billed charges,40% of total billed charges,1109.94,2761,
"Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 12.6 cm to 20",3900129,CDM,521,RC,12045,HCPCS,OUTPATIENT,,,796,477.6,,676.6,85,,541.28,Percent of total billed charges,85% of total billed charges,398,50,,644,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398,50,,2,percent of total billed charges,50% of total billed charges,254.32,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,254.32,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,302.48,38,,6007.04,percent of total billed charges,38% of total billed charges,318.4,40,,4,percent of total billed charges,40% of total billed charges,1110.94,2762,
LAYER CLOS OF WNDS OF NECK HANDS FEET A/O EXT GENI 12.6 CM TO 20 CM,3900129,CDM,450,RC,12045,HCPCS,OUTPATIENT,,,796,477.6,,676.6,85,,541.28,Percent of total billed charges,85% of total billed charges,398,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398,50,,4,percent of total billed charges,50% of total billed charges,254.32,31.95,,9.12,percent of total billed charges,31.95% of total billed charges,254.32,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.48,38,,6007.04,percent of total billed charges,38% of total billed charges,318.4,40,,8.288,percent of total billed charges,40% of total billed charges,1111.94,2763,
"Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 2.5 cm or Les",3900130,CDM,521,RC,12041,HCPCS,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,495.68,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,18.768,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,18.768,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,190,38,,4502.24,percent of total billed charges,38% of total billed charges,200,40,,23.504,percent of total billed charges,40% of total billed charges,1112.94,2764,
LAYER CLOS OF WNDS OF NECK HANDS FEET A/O EXT GENI 2.5 CM OR LESS,3900130,CDM,450,RC,12041,HCPCS,OUTPATIENT,,,796,477.6,,676.6,85,,541.28,Percent of total billed charges,85% of total billed charges,495.68,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,254.32,31.95,,1.84,percent of total billed charges,31.95% of total billed charges,254.32,31.95,,1.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.48,38,,34.96,percent of total billed charges,38% of total billed charges,318.4,40,,2.304,percent of total billed charges,40% of total billed charges,1113.94,2765,
"Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 2.6 cm to 7.5",3900131,CDM,521,RC,12042,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,948.82,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,254.64,31.95,,26.328,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,26.328,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,302.86,38,,387.6,percent of total billed charges,38% of total billed charges,318.8,40,,32.96,percent of total billed charges,40% of total billed charges,1114.94,2766,
LAYER CLOS OF WNDS OF NECK HANDS FEET A/O EXTE GENI 2.6 CM TO 7.5 CM,3900131,CDM,450,RC,12042,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,948.82,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,254.64,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,779.456,percent of total billed charges,38% of total billed charges,318.8,40,,6.4,percent of total billed charges,40% of total billed charges,1115.94,2767,
"Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 7.6 cm to 12.",3900132,CDM,521,RC,12044,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,398.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398.5,50,,5.632,percent of total billed charges,50% of total billed charges,254.64,31.95,,4.056,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,4.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,302.86,38,,1298.992,percent of total billed charges,38% of total billed charges,318.8,40,,5.08,percent of total billed charges,40% of total billed charges,1116.94,2768,
"LAYER CLOS OF WNDS OF NECK HANDS FEET A/O EXT GENI, 7.6 CM TO 12.5 CM",3900132,CDM,450,RC,12044,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,398.5,50,,5.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398.5,50,,3.792,percent of total billed charges,50% of total billed charges,254.64,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,177.84,percent of total billed charges,38% of total billed charges,318.8,40,,9.64,percent of total billed charges,40% of total billed charges,1117.94,2769,
"Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude Hands and",3900133,CDM,521,RC,12035,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,3.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,3.256,percent of total billed charges,50% of total billed charges,523.34,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,622.44,38,,63.84,percent of total billed charges,38% of total billed charges,655.2,40,,9.64,percent of total billed charges,40% of total billed charges,1118.94,2770,
LAYER CLOS OF WNDS OF SCALP AXI TRUNK A/O EXTREMITIES (EXCLUDING HANDS AND FEET),3900133,CDM,450,RC,12035,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,3.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,4.264,percent of total billed charges,50% of total billed charges,523.34,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,1064,percent of total billed charges,38% of total billed charges,655.2,40,,9.64,percent of total billed charges,40% of total billed charges,1119.94,2771,
"Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude Hands and",3900134,CDM,521,RC,12031,HCPCS,OUTPATIENT,,,399,239.4,,339.15,85,,271.32,Percent of total billed charges,85% of total billed charges,948.82,136.6,,4.264,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,14.52,fee schedule,136.60% of BCBS custom fee schedule,127.48,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,127.48,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,151.62,38,,1333.344,percent of total billed charges,38% of total billed charges,159.6,40,,9.64,percent of total billed charges,40% of total billed charges,1120.94,2772,
LAYER CLOS OF WDNS OF SCALP AXI TRUNK A/O EXTREMITIES (EXCLUDING HANDS AND FEET),3900134,CDM,450,RC,12031,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,948.82,136.6,,14.52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,5.392,fee schedule,136.60% of BCBS custom fee schedule,254.64,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,103.36,percent of total billed charges,38% of total billed charges,318.8,40,,9.64,percent of total billed charges,40% of total billed charges,1121.94,2773,
LAYER CLOS OF WNDS OF SCALP AXI TRUNK A/O EXTREMITIES (EXCLUDING HANDS AND FEET),3900135,CDM,450,RC,12032,HCPCS,OUTPATIENT,,,654,392.4,,555.9,85,,444.72,Percent of total billed charges,85% of total billed charges,948.82,136.6,,5.392,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,38.4,fee schedule,136.60% of BCBS custom fee schedule,208.95,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,208.95,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,248.52,38,,2128,percent of total billed charges,38% of total billed charges,261.6,40,,9.64,percent of total billed charges,40% of total billed charges,1122.94,2774,
"Repair, intermediate, wound, scalp, axillae, trunk, extremeties 20.1 to 30.0 cm",3900136,CDM,521,RC,12036,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,38.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,6.296,percent of total billed charges,50% of total billed charges,523.34,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,7.704,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,622.44,38,,185.44,percent of total billed charges,38% of total billed charges,655.2,40,,9.64,percent of total billed charges,40% of total billed charges,1123.94,2775,
LAYER CLOS OF WNDS OF SCALP AXI TRUNK A/O EXTREMITIES (EXCLUDING HANDS AND FEET),3900136,CDM,450,RC,12036,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,6.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,8.68,percent of total billed charges,50% of total billed charges,523.34,31.95,,118.088,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,118.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,31.92,percent of total billed charges,38% of total billed charges,655.2,40,,147.84,percent of total billed charges,40% of total billed charges,1124.94,2776,
"Repair intermediate, wounds of scalp, axillae, trunk, extremities 7.6 cm to 12.5",3900137,CDM,521,RC,12034,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,948.82,136.6,,8.68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,10.024,fee schedule,136.60% of BCBS custom fee schedule,254.64,31.95,,1.064,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,1.064,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,302.86,38,,164.768,percent of total billed charges,38% of total billed charges,318.8,40,,1.328,percent of total billed charges,40% of total billed charges,1125.94,2777,
LAYER CLOS OF WNDS OF SCALP AXI TRUNK A/O EXTREMITIES (EXCLUDING HANDS AND FEET),3900137,CDM,450,RC,12034,HCPCS,OUTPATIENT,,,797,478.2,,677.45,85,,541.96,Percent of total billed charges,85% of total billed charges,948.82,136.6,,10.024,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,948.82,136.6,,320,fee schedule,136.60% of BCBS custom fee schedule,254.64,31.95,,2.288,percent of total billed charges,31.95% of total billed charges,254.64,31.95,,2.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,68.4,percent of total billed charges,38% of total billed charges,318.8,40,,2.864,percent of total billed charges,40% of total billed charges,1126.94,2778,
"MANIPULATION ANKLE W ANESTHESIA, BILATERAL",3900138,CDM,450,RC,27860,HCPCS,OUTPATIENT,,,4618,2770.8,50,3925.3,85,,3140.24,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,320,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,2.464,fee schedule,136.60% of BCBS custom fee schedule,1475.45,31.95,,91.296,percent of total billed charges,31.95% of total billed charges,1475.45,31.95,,91.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1754.84,38,,57.76,percent of total billed charges,38% of total billed charges,1847.2,40,,114.296,percent of total billed charges,40% of total billed charges,1127.94,2779,
"MANIPULATION ANKLE W ANESTHESIA, LEFT",3900139,CDM,450,RC,27860,HCPCS,OUTPATIENT,,,4618,2770.8,,3925.3,85,,3140.24,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,2.464,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,1475.45,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,1475.45,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1754.84,38,,16.72,percent of total billed charges,38% of total billed charges,1847.2,40,,4,percent of total billed charges,40% of total billed charges,1128.94,2780,
"MANIPULATION ANKLE W ANESTHESIA, RIGHT",3900140,CDM,450,RC,27860,HCPCS,OUTPATIENT,,,4618,2770.8,,3925.3,85,,3140.24,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,1475.45,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,1475.45,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1754.84,38,,11.248,percent of total billed charges,38% of total billed charges,1847.2,40,,8,percent of total billed charges,40% of total billed charges,1129.94,2781,
OB CARE VAGINAL DELIVERY ONLY,3900141,CDM,450,RC,59409,HCPCS,OUTPATIENT,,,4273,2563.8,,3632.05,85,,2905.64,Percent of total billed charges,85% of total billed charges,5171.44,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5171.44,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,1501.96,35.15,,21.664,fee schedule,35.15% of LA custom fee schedule,1365.22,31.95,,21.664,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1623.74,38,,11.248,percent of total billed charges,38% of total billed charges,1365.22,31.95,,27.12,Fee Schedule,31.95% of LA custom fee schedule,1130.94,2782,
PUNCTURE ASPIRATION OF ABSCESS HEMATOMA BULLA OR CYST,3900142,CDM,450,RC,10160,HCPCS,OUTPATIENT,,,639,383.4,,543.15,85,,434.52,Percent of total billed charges,85% of total billed charges,319.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,319.5,50,,12.8,percent of total billed charges,50% of total billed charges,204.16,31.95,,1.544,percent of total billed charges,31.95% of total billed charges,204.16,31.95,,1.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,242.82,38,,14.592,percent of total billed charges,38% of total billed charges,255.6,40,,1.928,percent of total billed charges,40% of total billed charges,1131.94,2783,
REMOVAL CERUMEN IMPACTION  WITH TEST,3900143,CDM,450,RC,G0268,HCPCS,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,153.62,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,23.6,fee schedule,136.60% of BCBS custom fee schedule,40.42,35.15,,32.896,percent of total billed charges,35.15% of total billed charges,1045.08,31.95,,32.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.7,38,,11.856,percent of total billed charges,38% of total billed charges,36.74,31.95,,41.184,percent of total billed charges,31.95% of total billed charges,1132.94,2784,
REMOVAL FOREIGN BODY CORNEA,3900144,CDM,450,RC,65220,HCPCS,OUTPATIENT,,,233,139.8,,198.05,85,,158.44,Percent of total billed charges,85% of total billed charges,309.85,136.6,,23.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,309.85,136.6,,238.8,fee schedule,136.60% of BCBS custom fee schedule,81.9,35.15,,42.944,fee schedule,35.15% of LA custom fee schedule,74.44,31.95,,42.944,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.54,38,,11.856,percent of total billed charges,38% of total billed charges,74.44,31.95,,53.76,Fee Schedule,31.95% of LA custom fee schedule,1133.94,2785,
"REMOVAL FOREIGN BODY EYE, SUPERFICIAL",3900145,CDM,450,RC,65205,HCPCS,OUTPATIENT,,,262,157.2,,222.7,85,,178.16,Percent of total billed charges,85% of total billed charges,309.85,136.6,,238.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,309.85,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,83.71,31.95,,2.008,percent of total billed charges,31.95% of total billed charges,83.71,31.95,,2.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,99.56,38,,18.24,percent of total billed charges,38% of total billed charges,104.8,40,,2.512,percent of total billed charges,40% of total billed charges,1134.94,2786,
"REMOVAL FULL ARM/LEG CAST, BILATERAL",3900146,CDM,450,RC,29705,HCPCS,OUTPATIENT,,,401,240.6,50,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,270.44,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,270.44,136.6,,6.68,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,45.88,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,45.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,20.672,percent of total billed charges,38% of total billed charges,128.12,31.95,,57.44,Fee Schedule,31.95% of LA custom fee schedule,1135.94,2787,
"REMOVAL FULL ARM/LEG CAST, LEFT",3900147,CDM,450,RC,29705,HCPCS,OUTPATIENT,,,401,240.6,LT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,270.44,136.6,,6.68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,270.44,136.6,,6.704,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,10.896,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,10.896,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,14.896,percent of total billed charges,38% of total billed charges,128.12,31.95,,13.648,Fee Schedule,31.95% of LA custom fee schedule,1136.94,2788,
"REMOVAL FULL ARM/LEG CAST, RIGHT",3900148,CDM,450,RC,29705,HCPCS,OUTPATIENT,,,401,240.6,RT,340.85,85,,272.68,Percent of total billed charges,85% of total billed charges,270.44,136.6,,6.704,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,270.44,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,140.95,35.15,,2.008,fee schedule,35.15% of LA custom fee schedule,128.12,31.95,,2.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,152.38,38,,82.08,percent of total billed charges,38% of total billed charges,128.12,31.95,,2.512,Fee Schedule,31.95% of LA custom fee schedule,1137.94,2789,
"Removal foreign body, intranasal; procedure Tech Chg",3900149,CDM,521,RC,30300,HCPCS,OUTPATIENT,,,393,235.8,,334.05,85,,267.24,Percent of total billed charges,85% of total billed charges,153.62,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,125.56,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,125.56,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,149.34,38,,82.08,percent of total billed charges,38% of total billed charges,157.2,40,,1.92,percent of total billed charges,40% of total billed charges,1138.94,2790,
REMOVAL NASAL FOREIGN BODY   30300,3900149,CDM,450,RC,30300,HCPCS,OUTPATIENT,,,393,235.8,,334.05,85,,267.24,Percent of total billed charges,85% of total billed charges,153.62,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,125.56,31.95,,107.352,percent of total billed charges,31.95% of total billed charges,125.56,31.95,,107.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,149.34,38,,13.984,percent of total billed charges,38% of total billed charges,157.2,40,,134.4,percent of total billed charges,40% of total billed charges,1139.94,2791,
"REMOVAL OF FOREIGN BODY, ELBOW OR UPPER ARM; DEEP",3900150,CDM,450,RC,24201,HCPCS,OUTPATIENT,,,4586,2751.6,,3898.1,85,,3118.48,Percent of total billed charges,85% of total billed charges,3754.75,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3754.75,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,1465.23,31.95,,75.296,percent of total billed charges,31.95% of total billed charges,1465.23,31.95,,75.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1742.68,38,,18.24,percent of total billed charges,38% of total billed charges,1834.4,40,,94.264,percent of total billed charges,40% of total billed charges,1140.94,2792,
"REMOVAL OF FOREIGN BODY,FOOT,SUB",3900151,CDM,450,RC,28190,HCPCS,OUTPATIENT,,,2851,1710.6,,2423.35,85,,1938.68,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,910.89,31.95,,40.576,percent of total billed charges,31.95% of total billed charges,910.89,31.95,,40.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1083.38,38,,15.2,percent of total billed charges,38% of total billed charges,1140.4,40,,50.8,percent of total billed charges,40% of total billed charges,1141.94,2793,
"REMOVAL OF FOREIGN BODY; SHOULDER; SUBCUTANEOUS, BILATERAL",3900152,CDM,450,RC,23330,HCPCS,OUTPATIENT,,,3305,1983,50,2809.25,85,,2247.4,Percent of total billed charges,85% of total billed charges,1737.65,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.65,136.6,,267.544,fee schedule,136.60% of BCBS custom fee schedule,1055.95,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,1055.95,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1255.9,38,,31.008,percent of total billed charges,38% of total billed charges,1322,40,,4,percent of total billed charges,40% of total billed charges,1142.94,2794,
"REMOVAL OF FOREIGN BODY; SHOULDER; SUBCUTANEOUS, LEFT",3900153,CDM,450,RC,23330,HCPCS,OUTPATIENT,,,3305,1983,LT,2809.25,85,,2247.4,Percent of total billed charges,85% of total billed charges,1737.65,136.6,,267.544,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.65,136.6,,321.048,fee schedule,136.60% of BCBS custom fee schedule,1055.95,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,1055.95,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1255.9,38,,22.8,percent of total billed charges,38% of total billed charges,1322,40,,4,percent of total billed charges,40% of total billed charges,1143.94,2795,
"REMOVAL OF FOREIGN BODY; SHOULDER; SUBCUTANEOUS, RIGHT",3900154,CDM,450,RC,23330,HCPCS,OUTPATIENT,,,3305,1983,RT,2809.25,85,,2247.4,Percent of total billed charges,85% of total billed charges,1737.65,136.6,,321.048,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.65,136.6,,1.576,fee schedule,136.60% of BCBS custom fee schedule,1055.95,31.95,,30.584,percent of total billed charges,31.95% of total billed charges,1055.95,31.95,,30.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1255.9,38,,23.336,percent of total billed charges,38% of total billed charges,1322,40,,38.288,percent of total billed charges,40% of total billed charges,1144.94,2796,
REMOVE FOREIGN BODY FROM EAR CANAL WO ANESTHESIA,3900155,CDM,450,RC,69200,HCPCS,OUTPATIENT,,,214,128.4,,181.9,85,,145.52,Percent of total billed charges,85% of total billed charges,153.62,136.6,,1.576,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,1033.832,fee schedule,136.60% of BCBS custom fee schedule,75.22,35.15,,1.824,fee schedule,35.15% of LA custom fee schedule,68.37,31.95,,1.824,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,81.32,38,,20.048,percent of total billed charges,38% of total billed charges,68.37,31.95,,2.288,Fee Schedule,31.95% of LA custom fee schedule,1145.94,2797,
REMOVE FOREIGN BODY PHARYNX  42809,3900156,CDM,450,RC,42809,HCPCS,OUTPATIENT,,,393,235.8,,334.05,85,,267.24,Percent of total billed charges,85% of total billed charges,153.62,136.6,,1033.832,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,138.14,35.15,,144.416,fee schedule,35.15% of LA custom fee schedule,125.56,31.95,,144.416,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,149.34,38,,20.048,percent of total billed charges,38% of total billed charges,125.56,31.95,,180.8,Fee Schedule,31.95% of LA custom fee schedule,1146.94,2798,
REPAIR OF NAIL BED  ED,3900157,CDM,450,RC,11760,HCPCS,OUTPATIENT,,,796,477.6,,676.6,85,,541.28,Percent of total billed charges,85% of total billed charges,388.35,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,388.35,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,279.79,35.15,,190.424,fee schedule,35.15% of LA custom fee schedule,254.32,31.95,,190.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,302.48,38,,13.984,percent of total billed charges,38% of total billed charges,254.32,31.95,,238.4,Fee Schedule,31.95% of LA custom fee schedule,1147.94,2799,
"REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM",3900158,CDM,450,RC,13151,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,23.44,percent of total billed charges,50% of total billed charges,523.34,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,19.76,percent of total billed charges,38% of total billed charges,655.2,40,,15.68,percent of total billed charges,40% of total billed charges,1148.94,2800,
"REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM",3900160,CDM,450,RC,13152,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,23.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,18,percent of total billed charges,50% of total billed charges,523.34,31.95,,20.192,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,20.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,40.432,percent of total billed charges,38% of total billed charges,655.2,40,,25.28,percent of total billed charges,40% of total billed charges,1149.94,2801,
"REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS",3900161,CDM,450,RC,13153,HCPCS,OUTPATIENT,,,559,335.4,,475.15,85,,380.12,Percent of total billed charges,85% of total billed charges,279.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,279.5,50,,48.4,percent of total billed charges,50% of total billed charges,178.6,31.95,,157.192,percent of total billed charges,31.95% of total billed charges,178.6,31.95,,157.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,212.42,38,,23.712,percent of total billed charges,38% of total billed charges,223.6,40,,196.8,percent of total billed charges,40% of total billed charges,1150.94,2802,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS",3900162,CDM,450,RC,13131,HCPCS,OUTPATIENT,,,654,392.4,,555.9,85,,444.72,Percent of total billed charges,85% of total billed charges,327,50,,48.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,327,50,,234,percent of total billed charges,50% of total billed charges,208.95,31.95,,242.824,percent of total billed charges,31.95% of total billed charges,208.95,31.95,,242.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,248.52,38,,20.368,percent of total billed charges,38% of total billed charges,261.6,40,,304,percent of total billed charges,40% of total billed charges,1151.94,2803,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS",3900163,CDM,450,RC,13132,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,1803.28,136.6,,234,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1803.28,136.6,,158.76,fee schedule,136.60% of BCBS custom fee schedule,523.34,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,23.712,percent of total billed charges,38% of total billed charges,655.2,40,,9.28,percent of total billed charges,40% of total billed charges,1152.94,2804,
"REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS",3900164,CDM,450,RC,13133,HCPCS,OUTPATIENT,,,654,392.4,,555.9,85,,444.72,Percent of total billed charges,85% of total billed charges,327,50,,158.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,327,50,,153.6,percent of total billed charges,50% of total billed charges,208.95,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,208.95,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,248.52,38,,23.648,percent of total billed charges,38% of total billed charges,261.6,40,,48.96,percent of total billed charges,40% of total billed charges,1153.94,2805,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM",3900165,CDM,450,RC,13120,HCPCS,OUTPATIENT,,,796,477.6,,676.6,85,,541.28,Percent of total billed charges,85% of total billed charges,398,50,,153.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,398,50,,25.2,percent of total billed charges,50% of total billed charges,254.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,254.32,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.48,38,,23.648,percent of total billed charges,38% of total billed charges,318.4,40,,0.96,percent of total billed charges,40% of total billed charges,1154.94,2806,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM",3900166,CDM,450,RC,13121,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,1803.28,136.6,,25.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1803.28,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,523.34,31.95,,36.296,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,36.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,23.648,percent of total billed charges,38% of total billed charges,655.2,40,,45.44,percent of total billed charges,40% of total billed charges,1155.94,2807,
"REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS",3900167,CDM,450,RC,13122,HCPCS,OUTPATIENT,,,339,203.4,,288.15,85,,230.52,Percent of total billed charges,85% of total billed charges,169.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,169.5,50,,1.6,percent of total billed charges,50% of total billed charges,108.31,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,108.31,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.82,38,,43.168,percent of total billed charges,38% of total billed charges,135.6,40,,50.88,percent of total billed charges,40% of total billed charges,1156.94,2808,
"REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM",3900168,CDM,450,RC,13100,HCPCS,OUTPATIENT,,,1638,982.8,,1392.3,85,,1113.84,Percent of total billed charges,85% of total billed charges,819,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,1.6,percent of total billed charges,50% of total billed charges,523.34,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,622.44,38,,43.168,percent of total billed charges,38% of total billed charges,655.2,40,,6.4,percent of total billed charges,40% of total billed charges,1157.94,2809,
"SHOULDER IMMOBILIZATION, BILATERAL",3900169,CDM,450,RC,29240,HCPCS,OUTPATIENT,,,232,139.2,50,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,51.6,percent of total billed charges,50% of total billed charges,81.55,35.15,,2.304,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,2.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,24.928,percent of total billed charges,38% of total billed charges,74.12,31.95,,2.88,Fee Schedule,31.95% of LA custom fee schedule,1158.94,2810,
"SHOULDER IMMOBILIZATION, LEFT",3900170,CDM,450,RC,29240,HCPCS,OUTPATIENT,,,232,139.2,LT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,51.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,69.2,percent of total billed charges,50% of total billed charges,81.55,35.15,,120.92,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,9.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,46.816,percent of total billed charges,38% of total billed charges,74.12,31.95,,109.912,Fee Schedule,31.95% of LA custom fee schedule,1159.94,2811,
"SHOULDER IMMOBILIZATION, RIGHT",3900171,CDM,450,RC,29240,HCPCS,OUTPATIENT,,,232,139.2,RT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,69.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,55.6,percent of total billed charges,50% of total billed charges,81.55,35.15,,120.92,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,9.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,23.408,percent of total billed charges,38% of total billed charges,74.12,31.95,,109.912,Fee Schedule,31.95% of LA custom fee schedule,1160.94,2812,
"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 12.6 cm",3900172,CDM,521,RC,12016,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,84,50,,55.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84,50,,56.4,percent of total billed charges,50% of total billed charges,53.68,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,28.272,percent of total billed charges,38% of total billed charges,67.2,40,,31.36,percent of total billed charges,40% of total billed charges,1161.94,2813,
SIMPLE REPAIR OF SUPERFICIAL WOUND OF FACE EAR EYELID NOSE LIP AND/OR MUCOUS MEM,3900172,CDM,450,RC,12016,HCPCS,OUTPATIENT,,,400,240,,340,85,,272,Percent of total billed charges,85% of total billed charges,200,50,,56.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,200,50,,99,percent of total billed charges,50% of total billed charges,127.8,31.95,,120.92,percent of total billed charges,31.95% of total billed charges,127.8,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,152,38,,59.28,percent of total billed charges,38% of total billed charges,160,40,,109.912,percent of total billed charges,40% of total billed charges,1162.94,2814,
"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 2.5 cm >",3900173,CDM,521,RC,12011,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,495.68,136.6,,99,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,44.384,percent of total billed charges,38% of total billed charges,67.2,40,,14.72,percent of total billed charges,40% of total billed charges,1163.94,2815,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS, EYELIDS NOSE LIPS AND/OR MUCOU",3900173,CDM,450,RC,12011,HCPCS,OUTPATIENT,,,276,165.6,,234.6,85,,187.68,Percent of total billed charges,85% of total billed charges,495.68,136.6,,5.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,501.6,fee schedule,136.60% of BCBS custom fee schedule,88.18,31.95,,6.792,percent of total billed charges,31.95% of total billed charges,88.18,31.95,,6.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.88,38,,44.384,percent of total billed charges,38% of total billed charges,110.4,40,,8.496,percent of total billed charges,40% of total billed charges,1164.94,2816,
"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 2.6 cm t",3900174,CDM,521,RC,12013,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,495.68,136.6,,501.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,234.64,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,234.64,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,44.384,percent of total billed charges,38% of total billed charges,67.2,40,,293.76,percent of total billed charges,40% of total billed charges,1165.94,2817,
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE EARS EYELIDS NOSE LIP AND/OR MUCOUS,3900174,CDM,450,RC,12013,HCPCS,OUTPATIENT,,,276,165.6,,234.6,85,,187.68,Percent of total billed charges,85% of total billed charges,495.68,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,88.18,31.95,,120.92,percent of total billed charges,31.95% of total billed charges,88.18,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.88,38,,59.28,percent of total billed charges,38% of total billed charges,110.4,40,,109.912,percent of total billed charges,40% of total billed charges,1166.94,2818,
"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 5.1 cm t",3900175,CDM,521,RC,12014,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,84,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84,50,,10,percent of total billed charges,50% of total billed charges,53.68,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,69.616,percent of total billed charges,38% of total billed charges,67.2,40,,15.04,percent of total billed charges,40% of total billed charges,1167.94,2819,
SIMPLE REPAIR OF SUPERFICIAL WOUND OF FACE EAR EYELID NOSE LIP AND/OR MUCOUS MEM,3900175,CDM,450,RC,12014,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,150,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,150,50,,5.6,percent of total billed charges,50% of total billed charges,95.85,31.95,,0.56,percent of total billed charges,31.95% of total billed charges,95.85,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,69.616,percent of total billed charges,38% of total billed charges,120,40,,0.512,percent of total billed charges,40% of total billed charges,1168.94,2820,
"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 7.6 cm t",3900176,CDM,521,RC,12015,HCPCS,OUTPATIENT,,,155,93,,131.75,85,,105.4,Percent of total billed charges,85% of total billed charges,77.5,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,77.5,50,,12.8,percent of total billed charges,50% of total billed charges,49.52,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,49.52,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,58.9,38,,69.616,percent of total billed charges,38% of total billed charges,62,40,,0.64,percent of total billed charges,40% of total billed charges,1169.94,2821,
SIMPLE REPAIR OF SUPERFICIAL WOUND OF FACE EAR EYELID NOSE LIP AND/OR MUCOUS MEM,3900176,CDM,450,RC,12015,HCPCS,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,175,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,175,50,,12.8,percent of total billed charges,50% of total billed charges,111.83,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,111.83,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,28.272,percent of total billed charges,38% of total billed charges,140,40,,14.08,percent of total billed charges,40% of total billed charges,1170.94,2822,
"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 30.0+ cm",3900177,CDM,521,RC,12018,HCPCS,OUTPATIENT,,,642,385.2,,545.7,85,,436.56,Percent of total billed charges,85% of total billed charges,321,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,321,50,,12.8,percent of total billed charges,50% of total billed charges,205.12,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,205.12,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,243.96,38,,69.616,percent of total billed charges,38% of total billed charges,256.8,40,,14.08,percent of total billed charges,40% of total billed charges,1171.94,2823,
SIMPLE REPAIR OF SUPERFICIAL WOUND OF FACE EARS EYELID NOSE LIP AND/OR MUCOUS ME,3900177,CDM,450,RC,12018,HCPCS,OUTPATIENT,,,642,385.2,,545.7,85,,436.56,Percent of total billed charges,85% of total billed charges,321,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,321,50,,12.8,percent of total billed charges,50% of total billed charges,205.12,31.95,,8.152,percent of total billed charges,31.95% of total billed charges,205.12,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,243.96,38,,95.152,percent of total billed charges,38% of total billed charges,256.8,40,,7.416,percent of total billed charges,40% of total billed charges,1172.94,2824,
"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 7.6 cm t",3900178,CDM,521,RC,12004,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,495.68,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,180,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,120.688,percent of total billed charges,38% of total billed charges,67.2,40,,0.32,percent of total billed charges,40% of total billed charges,1173.94,2825,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP NECK, AXILLAE EXTERNAL GENITALIA TR",3900178,CDM,450,RC,12004,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,495.68,136.6,,180,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,9.04,fee schedule,136.60% of BCBS custom fee schedule,95.85,31.95,,120.92,percent of total billed charges,31.95% of total billed charges,95.85,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,150.176,percent of total billed charges,38% of total billed charges,120,40,,109.912,percent of total billed charges,40% of total billed charges,1174.94,2826,
"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 2.5 cm >",3900179,CDM,521,RC,12001,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,495.68,136.6,,9.04,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,20.8,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,120.92,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,5.472,percent of total billed charges,38% of total billed charges,67.2,40,,109.912,percent of total billed charges,40% of total billed charges,1175.94,2827,
"SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA,",3900179,CDM,450,RC,12001,HCPCS,OUTPATIENT,,,276,165.6,,234.6,85,,187.68,Percent of total billed charges,85% of total billed charges,495.68,136.6,,20.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,16.8,fee schedule,136.60% of BCBS custom fee schedule,88.18,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,88.18,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.88,38,,5.472,percent of total billed charges,38% of total billed charges,110.4,40,,67.2,percent of total billed charges,40% of total billed charges,1176.94,2828,
"Repair Simple  Scalp, Neck, Axillae, Ext. Genital, Trunk and/or Extrem; 30.0+ cm",3900180,CDM,521,RC,12007,HCPCS,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,16.8,percent of total billed charges,50% of total billed charges,67.1,31.95,,631.336,percent of total billed charges,31.95% of total billed charges,67.1,31.95,,631.336,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,79.8,38,,5.472,percent of total billed charges,38% of total billed charges,84,40,,790.4,percent of total billed charges,40% of total billed charges,1177.94,2829,
SIM REP OF SUPER WNDS OF SCP NECK AXI EXT GENI TRNK A/O EXTR (INCLHANDS  FEET),3900180,CDM,450,RC,12007,HCPCS,OUTPATIENT,,,425,255,,361.25,85,,289,Percent of total billed charges,85% of total billed charges,212.5,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,212.5,50,,17.6,percent of total billed charges,50% of total billed charges,135.79,31.95,,248.44,percent of total billed charges,31.95% of total billed charges,135.79,31.95,,248.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,161.5,38,,4.56,percent of total billed charges,38% of total billed charges,170,40,,311.04,percent of total billed charges,40% of total billed charges,1178.94,2830,
"STRAPPING ANKLE/FOOT, BILATERAL",3900181,CDM,450,RC,29540,HCPCS,OUTPATIENT,,,232,139.2,50,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,6,percent of total billed charges,50% of total billed charges,81.55,35.15,,199.368,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,199.368,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,4.56,percent of total billed charges,38% of total billed charges,74.12,31.95,,249.6,Fee Schedule,31.95% of LA custom fee schedule,1179.94,2831,
"STRAPPING ANKLE/FOOT, LEFT",3900182,CDM,450,RC,29540,HCPCS,OUTPATIENT,,,232,139.2,LT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,3.6,percent of total billed charges,50% of total billed charges,81.55,35.15,,120.92,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,98.152,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,4.56,percent of total billed charges,38% of total billed charges,74.12,31.95,,109.912,Fee Schedule,31.95% of LA custom fee schedule,1180.94,2832,
"STRAPPING ANKLE/FOOT, RIGHT",3900183,CDM,450,RC,29540,HCPCS,OUTPATIENT,,,232,139.2,RT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,6,percent of total billed charges,50% of total billed charges,81.55,35.15,,120.92,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,98.152,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,7.6,percent of total billed charges,38% of total billed charges,74.12,31.95,,109.912,Fee Schedule,31.95% of LA custom fee schedule,1181.94,2833,
"STRAPPING ELBOW/WRIST, BILATERAL",3900184,CDM,450,RC,29260,HCPCS,OUTPATIENT,,,232,139.2,50,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,21.6,percent of total billed charges,50% of total billed charges,81.55,35.15,,541.872,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,541.872,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,10.944,percent of total billed charges,38% of total billed charges,74.12,31.95,,678.4,Fee Schedule,31.95% of LA custom fee schedule,1182.94,2834,
"STRAPPING ELBOW/WRIST, LEFT",3900185,CDM,450,RC,29260,HCPCS,OUTPATIENT,,,232,139.2,LT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,1320,percent of total billed charges,50% of total billed charges,81.55,35.15,,37.12,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,98.152,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,51.68,percent of total billed charges,38% of total billed charges,74.12,31.95,,33.736,Fee Schedule,31.95% of LA custom fee schedule,1183.94,2835,
"STRAPPING ELBOW/WRIST, RIGHT",3900186,CDM,450,RC,29260,HCPCS,OUTPATIENT,,,232,139.2,RT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,1320,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,56.52,percent of total billed charges,50% of total billed charges,81.55,35.15,,104.608,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,98.664,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,41.04,percent of total billed charges,38% of total billed charges,74.12,31.95,,95.08,Fee Schedule,31.95% of LA custom fee schedule,1184.94,2836,
"STRAPPING HAND/FINGER, BILATERAL",3900187,CDM,450,RC,29280,HCPCS,OUTPATIENT,,,232,139.2,50,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,56.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,31.168,percent of total billed charges,50% of total billed charges,81.55,35.15,,95.08,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,95.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,150.48,percent of total billed charges,38% of total billed charges,74.12,31.95,,119.04,Fee Schedule,31.95% of LA custom fee schedule,1185.94,2837,
"STRAPPING HAND/FINGER, LEFT",3900188,CDM,450,RC,29280,HCPCS,OUTPATIENT,,,232,139.2,LT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,31.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,6600,percent of total billed charges,50% of total billed charges,81.55,35.15,,95.08,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,95.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,10.032,percent of total billed charges,38% of total billed charges,74.12,31.95,,119.04,Fee Schedule,31.95% of LA custom fee schedule,1186.94,2838,
"STRAPPING HAND/FINGER, RIGHT",3900189,CDM,450,RC,29280,HCPCS,OUTPATIENT,,,232,139.2,RT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,6600,percent of total billed charges,50% of total billed charges,81.55,35.15,,95.08,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,95.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,7.904,percent of total billed charges,38% of total billed charges,74.12,31.95,,119.04,Fee Schedule,31.95% of LA custom fee schedule,1187.94,2839,
"STRAPPING HIP, BILATERAL",3900190,CDM,450,RC,29520,HCPCS,OUTPATIENT,,,210,126,50,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,6600,percent of total billed charges,50% of total billed charges,73.82,35.15,,95.08,fee schedule,35.15% of LA custom fee schedule,67.1,31.95,,95.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,79.8,38,,7.904,percent of total billed charges,38% of total billed charges,67.1,31.95,,119.04,Fee Schedule,31.95% of LA custom fee schedule,1188.94,2840,
"STRAPPING HIP, LEFT",3900191,CDM,450,RC,29520,HCPCS,OUTPATIENT,,,210,126,LT,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,6600,percent of total billed charges,50% of total billed charges,73.82,35.15,,33.736,fee schedule,35.15% of LA custom fee schedule,67.1,31.95,,33.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,79.8,38,,66.528,percent of total billed charges,38% of total billed charges,67.1,31.95,,42.24,Fee Schedule,31.95% of LA custom fee schedule,1189.94,2841,
"STRAPPING HIP, RIGHT",3900192,CDM,450,RC,29520,HCPCS,OUTPATIENT,,,210,126,RT,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,6600,percent of total billed charges,50% of total billed charges,73.82,35.15,,95.08,fee schedule,35.15% of LA custom fee schedule,67.1,31.95,,95.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,79.8,38,,8.512,percent of total billed charges,38% of total billed charges,67.1,31.95,,119.04,Fee Schedule,31.95% of LA custom fee schedule,1190.94,2842,
"STRAPPING KNEE, BILATERAL",3900193,CDM,450,RC,29530,HCPCS,OUTPATIENT,,,232,139.2,50,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,936,percent of total billed charges,50% of total billed charges,81.55,35.15,,95.08,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,95.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,10.032,percent of total billed charges,38% of total billed charges,74.12,31.95,,119.04,Fee Schedule,31.95% of LA custom fee schedule,1191.94,2843,
"STRAPPING KNEE, LEFT",3900194,CDM,450,RC,29530,HCPCS,OUTPATIENT,,,232,139.2,LT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,1120,percent of total billed charges,50% of total billed charges,81.55,35.15,,353.496,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,353.496,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,10.032,percent of total billed charges,38% of total billed charges,74.12,31.95,,442.56,Fee Schedule,31.95% of LA custom fee schedule,1192.94,2844,
"STRAPPING KNEE, RIGHT",3900195,CDM,450,RC,29530,HCPCS,OUTPATIENT,,,232,139.2,RT,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,1120,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,853.72,percent of total billed charges,50% of total billed charges,81.55,35.15,,7.672,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,7.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,20.368,percent of total billed charges,38% of total billed charges,74.12,31.95,,9.6,Fee Schedule,31.95% of LA custom fee schedule,1193.94,2845,
STRAPPING TOES ED,3900196,CDM,450,RC,29550,HCPCS,OUTPATIENT,,,232,139.2,,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,853.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,841.2,percent of total billed charges,50% of total billed charges,81.55,35.15,,6.392,fee schedule,35.15% of LA custom fee schedule,74.12,31.95,,6.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.16,38,,70.184,percent of total billed charges,38% of total billed charges,74.12,31.95,,8,Fee Schedule,31.95% of LA custom fee schedule,1194.94,2846,
THORACENTESIS W TUBE INSERTION,3900197,CDM,402,RC,32555,HCPCS,OUTPATIENT,,,1941,1164.6,,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1734.79,136.6,,841.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1734.79,136.6,,96.776,fee schedule,136.60% of BCBS custom fee schedule,620.15,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,620.15,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,265,100,,37.88,case rate,pays based on per visit rate,776.4,40,,48,percent of total billed charges,40% of total billed charges,1195.94,2847,
THROMBOLYSIS CEREBRAL IV INFUSION,3900198,CDM,450,RC,37195,HCPCS,OUTPATIENT,,,735,441,,624.75,85,,499.8,Percent of total billed charges,85% of total billed charges,367.5,50,,96.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,367.5,50,,72,percent of total billed charges,50% of total billed charges,258.35,35.15,,30.672,fee schedule,35.15% of LA custom fee schedule,234.83,31.95,,30.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,279.3,38,,70.184,percent of total billed charges,38% of total billed charges,234.83,31.95,,38.4,Fee Schedule,31.95% of LA custom fee schedule,1196.94,2848,
TRACHEOSTOMY EMR TRNS,3900199,CDM,450,RC,31603,HCPCS,OUTPATIENT,,,2181,1308.6,,1853.85,85,,1483.08,Percent of total billed charges,85% of total billed charges,2028.62,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2028.62,136.6,,336,fee schedule,136.60% of BCBS custom fee schedule,696.83,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,696.83,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,828.78,38,,27.968,percent of total billed charges,38% of total billed charges,872.4,40,,38.4,percent of total billed charges,40% of total billed charges,1197.94,2849,
TRACHEOSTOMY ER CRICOTHYROID  31605,3900200,CDM,450,RC,31605,HCPCS,OUTPATIENT,,,1533,919.8,,1303.05,85,,1042.44,Percent of total billed charges,85% of total billed charges,2028.62,136.6,,336,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2028.62,136.6,,13.088,fee schedule,136.60% of BCBS custom fee schedule,538.85,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,489.79,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,582.54,38,,28.88,percent of total billed charges,38% of total billed charges,489.79,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,1198.94,2850,
"TREATMENT DISLOCATION ANKLE WITH ANESTHESIA, WITH OR WITHOUT FIXATION, BILATERAL",3900201,CDM,450,RC,27842,HCPCS,OUTPATIENT,,,3982,2389.2,,3384.7,85,,2707.76,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,13.088,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,1272.25,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,1272.25,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1513.16,38,,25.232,percent of total billed charges,38% of total billed charges,1592.8,40,,27.2,percent of total billed charges,40% of total billed charges,1199.94,2851,
"TREATMENT DISLOCATION ANKLE WITH ANESTHESIA, WITH OR WITHOUT FIXATION, LEFT",3900202,CDM,450,RC,27842,HCPCS,OUTPATIENT,,,3982,2389.2,,3384.7,85,,2707.76,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,454.936,fee schedule,136.60% of BCBS custom fee schedule,1272.25,31.95,,34.272,percent of total billed charges,31.95% of total billed charges,1272.25,31.95,,34.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1513.16,38,,25.232,percent of total billed charges,38% of total billed charges,1592.8,40,,42.904,percent of total billed charges,40% of total billed charges,1200.94,2852,
"TREATMENT DISLOCATION ANKLE WITH ANESTHESIA, WITH OR WITHOUT FIXATION, RIGHT",3900203,CDM,450,RC,27842,HCPCS,OUTPATIENT,,,3982,2389.2,,3384.7,85,,2707.76,Percent of total billed charges,85% of total billed charges,3590.26,136.6,,454.936,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3590.26,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,1272.25,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,1272.25,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1513.16,38,,11.248,percent of total billed charges,38% of total billed charges,1592.8,40,,5.76,percent of total billed charges,40% of total billed charges,1201.94,2853,
UNLISTED PROCEDURE RECTUM,3900204,CDM,450,RC,45999,HCPCS,OUTPATIENT,,,1892,1135.2,,1608.2,85,,1286.56,Percent of total billed charges,85% of total billed charges,877.38,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,877.38,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,665.04,35.15,,7.16,percent of total billed charges,35.15% of total billed charges,1114.42,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,718.96,38,,60.8,percent of total billed charges,38% of total billed charges,604.49,31.95,,8.96,percent of total billed charges,31.95% of total billed charges,1202.94,2854,
RAPE EXAM,3900205,CDM,450,RC,58999,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,42.61,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,42.61,136.6,,1.84,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,34.504,percent of total billed charges,35.15% of total billed charges,1114.42,31.95,,34.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,25.144,percent of total billed charges,38% of total billed charges,63.9,31.95,,43.2,percent of total billed charges,31.95% of total billed charges,1203.94,2855,
99291 - ED Critical Care,3900206,CDM,450,RC,99291,HCPCS,OUTPATIENT,,,2540,1524,,2159,85,,1727.2,Percent of total billed charges,85% of total billed charges,1617.95,136.6,,1.84,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1617.95,136.6,,13.24,fee schedule,136.60% of BCBS custom fee schedule,892.81,35.15,,1.688,fee schedule,35.15% of LA custom fee schedule,811.53,31.95,,98.664,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,2000,38,,19.152,percent of total billed charges,38% of total billed charges,811.53,31.95,,1.536,Fee Schedule,31.95% of LA custom fee schedule,1204.94,2856,
99291 - ED Critical Care,3900206,CDM,450,RC,99291,HCPCS,OUTPATIENT,,,2540,1524,,2159,85,,1727.2,Percent of total billed charges,85% of total billed charges,1617.95,136.6,,13.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1617.95,136.6,,2.88,fee schedule,136.60% of BCBS custom fee schedule,892.81,35.15,,120.92,fee schedule,35.15% of LA custom fee schedule,811.53,31.95,,99.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,2000,38,,20.672,percent of total billed charges,38% of total billed charges,811.53,31.95,,109.912,Fee Schedule,31.95% of LA custom fee schedule,1205.94,2857,
"99292 - ED Critical Care, each 30 min",3900207,CDM,450,RC,99292,HCPCS,OUTPATIENT,,,328,196.8,,278.8,85,,223.04,Percent of total billed charges,85% of total billed charges,1112.44,136.6,,2.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1112.44,136.6,,98.16,fee schedule,136.60% of BCBS custom fee schedule,115.29,35.15,,120.92,percent of total billed charges,35.15% of total billed charges,1148.6,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.64,38,,10.64,percent of total billed charges,38% of total billed charges,104.8,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,1206.94,2858,
"99292 - ED Critical Care, each 30 min",3900207,CDM,450,RC,99292,HCPCS,OUTPATIENT,,,328,196.8,,278.8,85,,223.04,Percent of total billed charges,85% of total billed charges,1112.44,136.6,,98.16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1112.44,136.6,,0.72,fee schedule,136.60% of BCBS custom fee schedule,115.29,35.15,,120.92,percent of total billed charges,35.15% of total billed charges,1148.6,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.64,38,,10.64,percent of total billed charges,38% of total billed charges,104.8,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,1207.94,2859,
Dx laryngoscopy excl nb,3900209,CDM,450,RC,31525,HCPCS,OUTPATIENT,,,4100,2460,,3485,85,,2788,Percent of total billed charges,85% of total billed charges,3870.4,136.6,,0.72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3870.4,136.6,,3.76,fee schedule,136.60% of BCBS custom fee schedule,1309.95,31.95,,29.448,percent of total billed charges,31.95% of total billed charges,1309.95,31.95,,29.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1558,38,,6.08,percent of total billed charges,38% of total billed charges,1640,40,,36.864,percent of total billed charges,40% of total billed charges,1208.94,2860,
Inject trigger points 3/>,3900210,CDM,450,RC,20553,HCPCS,OUTPATIENT,,,740,444,,629,85,,503.2,Percent of total billed charges,85% of total billed charges,567.44,136.6,,3.76,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,18.52,fee schedule,136.60% of BCBS custom fee schedule,260.11,35.15,,2.016,fee schedule,35.15% of LA custom fee schedule,236.43,31.95,,2.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,281.2,38,,20.672,percent of total billed charges,38% of total billed charges,236.43,31.95,,2.528,Fee Schedule,31.95% of LA custom fee schedule,1209.94,2861,
INJ TRIGGER POINT 1/2 MUSCL,3900212,CDM,450,RC,20552,HCPCS,OUTPATIENT,,,740,444,,629,85,,503.2,Percent of total billed charges,85% of total billed charges,567.44,136.6,,18.52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,136,fee schedule,136.60% of BCBS custom fee schedule,260.11,35.15,,95.08,fee schedule,35.15% of LA custom fee schedule,236.43,31.95,,95.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,281.2,38,,4.56,percent of total billed charges,38% of total billed charges,236.43,31.95,,119.04,Fee Schedule,31.95% of LA custom fee schedule,1210.94,2862,
Treatment of tibia fracture,3900215,CDM,450,RC,27752,HCPCS,OUTPATIENT,,,3940,2364,,3349,85,,2679.2,Percent of total billed charges,85% of total billed charges,861.18,136.6,,136,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,169.96,fee schedule,136.60% of BCBS custom fee schedule,1258.83,31.95,,95.08,percent of total billed charges,31.95% of total billed charges,1258.83,31.95,,95.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1497.2,38,,5.472,percent of total billed charges,38% of total billed charges,1576,40,,119.04,percent of total billed charges,40% of total billed charges,1211.94,2863,
CLTX BIMALLEOLAR ANKLE FRACTURE W/O MANJ,3900216,CDM,450,RC,27808,HCPCS,OUTPATIENT,,,620,372,,527,85,,421.6,Percent of total billed charges,85% of total billed charges,430.58,136.6,,169.96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,3.08,fee schedule,136.60% of BCBS custom fee schedule,198.09,31.95,,199.368,percent of total billed charges,31.95% of total billed charges,198.09,31.95,,199.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,235.6,38,,5.472,percent of total billed charges,38% of total billed charges,248,40,,249.6,percent of total billed charges,40% of total billed charges,1212.94,2864,
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,3900217,CDM,372,RC,99151,HCPCS,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,3.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,5,percent of total billed charges,50% of total billed charges,159.75,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,51,percent of total billed charges,38% of total billed charges,200,40,,4.32,percent of total billed charges,40% of total billed charges,1213.94,2865,
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,3900218,CDM,372,RC,99152,HCPCS,OUTPATIENT,,,400,240,,340,85,,272,Percent of total billed charges,85% of total billed charges,200,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,200,50,,3.48,percent of total billed charges,50% of total billed charges,127.8,31.95,,5.824,percent of total billed charges,31.95% of total billed charges,127.8,31.95,,5.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,152,38,,51,percent of total billed charges,38% of total billed charges,160,40,,7.288,percent of total billed charges,40% of total billed charges,1214.94,2866,
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,3900219,CDM,372,RC,99153,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,150,50,,3.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,150,50,,5,percent of total billed charges,50% of total billed charges,95.85,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,95.85,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,39.52,percent of total billed charges,38% of total billed charges,120,40,,10.56,percent of total billed charges,40% of total billed charges,1215.94,2867,
INS NEW/RPLCMT PRM PACEMAKR W/TRANS ELTRD ATRIA,3900220,CDM,450,RC,33206,HCPCS,OUTPATIENT,,,19760,11856,,16796,85,,13436.8,Percent of total billed charges,85% of total billed charges,17907.3,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17907.3,136.6,,191.92,fee schedule,136.60% of BCBS custom fee schedule,6945.64,35.15,,1.152,fee schedule,35.15% of LA custom fee schedule,6313.32,31.95,,1.152,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7508.8,38,,8.816,percent of total billed charges,38% of total billed charges,6313.32,31.95,,1.44,Fee Schedule,31.95% of LA custom fee schedule,1216.94,2868,
INS NEW/RPLC PRM PACEMAKER W/TRANSV ELTRD VENTR,3900221,CDM,450,RC,33207,HCPCS,OUTPATIENT,,,19760,11856,,16796,85,,13436.8,Percent of total billed charges,85% of total billed charges,17907.3,136.6,,191.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17907.3,136.6,,191.92,fee schedule,136.60% of BCBS custom fee schedule,6945.64,35.15,,8.688,fee schedule,35.15% of LA custom fee schedule,6313.32,31.95,,8.688,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7508.8,38,,23.408,percent of total billed charges,38% of total billed charges,6313.32,31.95,,10.88,Fee Schedule,31.95% of LA custom fee schedule,1217.94,2869,
INS NEW/RPLCMT PRM PM W/TRANSV ELTRD ATRIALVENT,3900222,CDM,450,RC,33208,HCPCS,OUTPATIENT,,,19760,11856,,16796,85,,13436.8,Percent of total billed charges,85% of total billed charges,20936.35,136.6,,191.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20936.35,136.6,,214.56,fee schedule,136.60% of BCBS custom fee schedule,6945.64,35.15,,3.832,fee schedule,35.15% of LA custom fee schedule,6313.32,31.95,,3.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,7508.8,38,,10.336,percent of total billed charges,38% of total billed charges,6313.32,31.95,,4.8,Fee Schedule,31.95% of LA custom fee schedule,1218.94,2870,
INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX,3900223,CDM,450,RC,33211,HCPCS,OUTPATIENT,,,14810,8886,,12588.5,85,,10070.8,Percent of total billed charges,85% of total billed charges,8557.88,136.6,,214.56,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8557.88,136.6,,49.24,fee schedule,136.60% of BCBS custom fee schedule,5205.72,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,4731.8,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5627.8,38,,10.64,percent of total billed charges,38% of total billed charges,4731.8,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,1219.94,2871,
CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MANJ,3900224,CDM,360,RC,27267,HCPCS,OUTPATIENT,,,7870,4722,,6689.5,85,,5351.6,Percent of total billed charges,85% of total billed charges,473.76,136.6,,49.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,473.76,136.6,,5.68,fee schedule,136.60% of BCBS custom fee schedule,2514.47,31.95,,23.768,percent of total billed charges,31.95% of total billed charges,2514.47,31.95,,23.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,8.512,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,3148,40,,29.76,percent of total billed charges,40% of total billed charges,1220.94,2872,
CLOSED TX FEMORAL FRACTURE PROX HEAD W/MANJ,3900225,CDM,360,RC,27268,HCPCS,OUTPATIENT,,,1660,996,,1411,85,,1128.8,Percent of total billed charges,85% of total billed charges,4058.52,136.6,,5.68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4058.52,136.6,,1.24,fee schedule,136.60% of BCBS custom fee schedule,530.37,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,530.37,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3050,100,,32.528,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,664,40,,8.64,percent of total billed charges,40% of total billed charges,1221.94,2873,
CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ,3900226,CDM,360,RC,27238,HCPCS,OUTPATIENT,,,3940,2364,,3349,85,,2679.2,Percent of total billed charges,85% of total billed charges,430.58,136.6,,1.24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,430.58,136.6,,4.16,fee schedule,136.60% of BCBS custom fee schedule,1258.83,31.95,,31.44,percent of total billed charges,31.95% of total billed charges,1258.83,31.95,,31.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,43.472,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1576,40,,39.36,percent of total billed charges,40% of total billed charges,1222.94,2874,
CLTX INTR/PERI/SBTRCHNTC FEMORAL FX W/MANJ,3900227,CDM,360,RC,27240,HCPCS,OUTPATIENT,,,2960,1776,,2516,85,,2012.8,Percent of total billed charges,85% of total billed charges,1480,50,,4.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1480,50,,28.52,percent of total billed charges,50% of total billed charges,945.72,31.95,,0.408,percent of total billed charges,31.95% of total billed charges,945.72,31.95,,0.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,43.472,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1184,40,,0.512,percent of total billed charges,40% of total billed charges,1223.94,2875,
US Head/Neck Soft Tissue,3900300,CDM,402,RC,76536,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,28.52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,28.52,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,56.952,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,56.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,15.2,case rate,pays based on per visit rate,129.08,31.95,,71.304,Fee Schedule,31.95% of LA custom fee schedule,1224.94,2876,
US Head/Neck Soft Tissue ED,3900300,CDM,402,RC,76536,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,28.52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,8.56,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,36.856,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,36.856,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,22.496,case rate,pays based on per visit rate,129.08,31.95,,46.144,Fee Schedule,31.95% of LA custom fee schedule,1225.94,2877,
US Abdl Aorta Screen AAA ED,3900301,CDM,402,RC,76706,HCPCS,OUTPATIENT,,,327,196.2,,277.95,85,,222.36,Percent of total billed charges,85% of total billed charges,165.22,136.6,,8.56,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,165.22,136.6,,63.2,fee schedule,136.60% of BCBS custom fee schedule,114.94,35.15,,4.088,fee schedule,35.15% of LA custom fee schedule,104.48,31.95,,4.088,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,7.904,case rate,pays based on per visit rate,104.48,31.95,,5.12,Fee Schedule,31.95% of LA custom fee schedule,1226.94,2878,
Ear impaction 69210,3900302,CDM,450,RC,69210,HCPCS,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,153.62,136.6,,63.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,29.84,fee schedule,136.60% of BCBS custom fee schedule,40.42,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,36.74,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,43.7,38,,10.336,percent of total billed charges,38% of total billed charges,36.74,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,1227.94,2879,
C-line over 5 years 36556,3900304,CDM,490,RC,36556,HCPCS,OUTPATIENT,,,2350,1410,,1997.5,85,,1598,Percent of total billed charges,85% of total billed charges,2060.64,136.6,,29.84,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2060.64,136.6,,233.88,fee schedule,136.60% of BCBS custom fee schedule,395.29,110,,5.904,fee schedule,110% of Asc Tier Grouping Fee Schedule,359.35,100,,99.432,fee schedule,100% of Asc Tier Grouping Fee Schedule,,,,,other,Not separately reimbursable,500,100,,7.6,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,359.35,100,,5.368,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1228.94,2880,
US Chest,3900305,CDM,402,RC,76604,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,233.88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,45.28,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,6.648,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,6.648,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,7.6,case rate,pays based on per visit rate,129.08,31.95,,8.32,Fee Schedule,31.95% of LA custom fee schedule,1229.94,2881,
US Chest ED,3900305,CDM,402,RC,76604,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,45.28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,48.64,case rate,pays based on per visit rate,129.08,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,1230.94,2882,
Excision lesion 11400,3900306,CDM,450,RC,11400,HCPCS,OUTPATIENT,,,1275,765,,1083.75,85,,867,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,13.92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,14.36,fee schedule,136.60% of BCBS custom fee schedule,407.36,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,407.36,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,484.5,38,,22.8,percent of total billed charges,38% of total billed charges,510,40,,47.04,percent of total billed charges,40% of total billed charges,1231.94,2883,
Excision lesion face/ears 11441,3900308,CDM,450,RC,11441,HCPCS,OUTPATIENT,,,2564,1538.4,,2179.4,85,,1743.52,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,14.36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,191.92,fee schedule,136.60% of BCBS custom fee schedule,819.2,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,819.2,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,974.32,38,,22.8,percent of total billed charges,38% of total billed charges,1025.6,40,,1.6,percent of total billed charges,40% of total billed charges,1232.94,2884,
Vaginal delivery 59410,3900309,CDM,450,RC,59410,HCPCS,OUTPATIENT,,,4273,2563.8,,3632.05,85,,2905.64,Percent of total billed charges,85% of total billed charges,2136.5,50,,191.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2136.5,50,,169.96,percent of total billed charges,50% of total billed charges,1501.96,35.15,,11.808,percent of total billed charges,35.15% of total billed charges,1148.6,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1623.74,38,,25.84,percent of total billed charges,38% of total billed charges,1365.22,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,1233.94,2885,
US Abdomen Complete,3900310,CDM,402,RC,76700,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,169.96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,269.44,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,0.752,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,0.752,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,28.88,case rate,pays based on per visit rate,129.08,31.95,,0.944,Fee Schedule,31.95% of LA custom fee schedule,1234.94,2886,
US Abdomen Complete ED,3900310,CDM,402,RC,76700,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,269.44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,3.656,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,99.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,34.048,case rate,pays based on per visit rate,129.08,31.95,,3.32,Fee Schedule,31.95% of LA custom fee schedule,1235.94,2887,
US Abdomen Limited,3900315,CDM,402,RC,76705,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,57,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,57,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,34.048,case rate,pays based on per visit rate,129.08,31.95,,71.36,Fee Schedule,31.95% of LA custom fee schedule,1236.94,2888,
US Abdomen Limited ED,3900315,CDM,402,RC,76705,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,126.096,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,40.64,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,40.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,34.048,case rate,pays based on per visit rate,129.08,31.95,,50.88,Fee Schedule,31.95% of LA custom fee schedule,1237.94,2889,
US Retroperitoneal Complete,3900320,CDM,402,RC,76770,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,126.096,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,41.2,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,0.256,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,0.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,34.048,case rate,pays based on per visit rate,129.08,31.95,,0.32,Fee Schedule,31.95% of LA custom fee schedule,1238.94,2890,
US Retroperitoneal Complete ED,3900320,CDM,402,RC,76770,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,41.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,6.2,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,31.096,case rate,pays based on per visit rate,129.08,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1239.94,2891,
DEBRIDEMENT EPI/DERM 97597,3900321,CDM,450,RC,97597,HCPCS,OUTPATIENT,,,585,351,,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,170.87,136.6,,6.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,170.87,136.6,,6.472,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,13.544,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,222.3,38,,31.008,percent of total billed charges,38% of total billed charges,186.91,31.95,,16.96,percent of total billed charges,31.95% of total billed charges,1240.94,2892,
REMOVAL IMPACT CERUM 69209,3900322,CDM,450,RC,69209,HCPCS,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,235.32,136.6,,6.472,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,235.32,136.6,,126.944,fee schedule,136.60% of BCBS custom fee schedule,73.82,35.15,,6.624,fee schedule,35.15% of LA custom fee schedule,67.1,31.95,,6.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,79.8,38,,31.096,percent of total billed charges,38% of total billed charges,67.1,31.95,,8.288,Fee Schedule,31.95% of LA custom fee schedule,1241.94,2893,
US Extremity Nonvascular Ltd ED,3900324,CDM,402,RC,76882,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,29.37,136.6,,126.944,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.37,136.6,,41.2,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,5.624,fee schedule,35.15% of LA custom fee schedule,95.85,31.95,,5.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,11.248,case rate,pays based on per visit rate,95.85,31.95,,7.04,Fee Schedule,31.95% of LA custom fee schedule,1242.94,2894,
US Retroperitoneal Limited,3900325,CDM,402,RC,76775,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,41.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,420,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,32.224,case rate,pays based on per visit rate,129.08,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1243.94,2895,
US Retroperitoneal Limited ED,3900325,CDM,402,RC,76775,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,420,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,420,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,36.808,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,36.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,8.816,case rate,pays based on per visit rate,129.08,31.95,,46.08,Fee Schedule,31.95% of LA custom fee schedule,1244.94,2896,
US Guidance Needle Placement,3900328,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,400,240,TC,340,85,,272,Percent of total billed charges,85% of total billed charges,194.19,136.6,,420,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,584,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,5.368,fee schedule,35.15% of LA custom fee schedule,127.8,31.95,,5.368,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,10.944,case rate,pays based on per visit rate,127.8,31.95,,6.72,Fee Schedule,31.95% of LA custom fee schedule,1245.94,2897,
US GUIDE FOR BIOPSY,3900328,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,400,240,TC,340,85,,272,Percent of total billed charges,85% of total billed charges,194.19,136.6,,584,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,52,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,0.56,fee schedule,35.15% of LA custom fee schedule,127.8,31.95,,99.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,10.944,case rate,pays based on per visit rate,127.8,31.95,,0.512,Fee Schedule,31.95% of LA custom fee schedule,1246.94,2898,
US GUIDE FOR BIOPSY PROFEE,3900328,CDM,960,RC,76942,HCPCS,OUTPATIENT,,,250,150,TC,,,,,other,Not separately reimbursable,,,,52,other,Not separately reimbursable,73.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,52,other,Not separately reimbursable,,,,24.28,other,Not separately reimbursable,,31.95,,24.28,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.944,other,Not separately reimbursable,,,,30.4,other,Not separately reimbursable,1247.94,2899,
US Kidney Transplant Right,3900330,CDM,402,RC,76776,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,10.224,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,10.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,10.944,case rate,pays based on per visit rate,129.08,31.95,,12.8,Fee Schedule,31.95% of LA custom fee schedule,1248.94,2900,
US Kidney Transplant Left,3900330,CDM,402,RC,76776,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,16.312,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,16.416,case rate,pays based on per visit rate,129.08,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,1249.94,2901,
US Kidney Transplant Left ED,3900330,CDM,402,RC,76776,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,16.312,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,9.6,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,16.968,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,16.968,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,25.96,case rate,pays based on per visit rate,129.08,31.95,,21.248,Fee Schedule,31.95% of LA custom fee schedule,1250.94,2902,
US Kidney Transplant Right ED,3900330,CDM,402,RC,76776,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,228.48,136.6,,9.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,3.224,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,3.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,25.96,case rate,pays based on per visit rate,129.08,31.95,,4.032,Fee Schedule,31.95% of LA custom fee schedule,1251.94,2903,
US Pregnancy 1st Trimester,3900335,CDM,402,RC,76801,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,243.91,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,243.91,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,367.04,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,367.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,67.792,case rate,pays based on per visit rate,129.08,31.95,,459.52,Fee Schedule,31.95% of LA custom fee schedule,1252.94,2904,
US Pregnancy 1st Trimester ED,3900335,CDM,402,RC,76801,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,243.91,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,243.91,136.6,,5.216,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,1.536,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,1.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,47.12,case rate,pays based on per visit rate,129.08,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,1253.94,2905,
ECHO DOPPLER FETAL PW/CW COMPLETE,3900337,CDM,402,RC,76827,HCPCS,OUTPATIENT,,,275,165,,233.75,85,,187,Percent of total billed charges,85% of total billed charges,227.99,136.6,,5.216,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,227.99,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,87.86,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,24.016,case rate,pays based on per visit rate,87.86,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,1254.94,2906,
US Pelvis Non-OB Complete,3900340,CDM,402,RC,76856,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,1426,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,3.32,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,3.32,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,48.128,case rate,pays based on per visit rate,129.08,31.95,,4.16,Fee Schedule,31.95% of LA custom fee schedule,1255.94,2907,
US Pelvis Non-OB Complete ED,3900340,CDM,402,RC,76856,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,216.01,136.6,,1426,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,930,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,35.016,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,35.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,37.392,case rate,pays based on per visit rate,129.08,31.95,,43.84,Fee Schedule,31.95% of LA custom fee schedule,1256.94,2908,
US Pelvis Non-OB Limited,3900345,CDM,402,RC,76857,HCPCS,OUTPATIENT,,,360,216,,306,85,,244.8,Percent of total billed charges,85% of total billed charges,184.33,136.6,,930,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,184.33,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,2.696,fee schedule,35.15% of LA custom fee schedule,115.02,31.95,,2.696,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,41.648,case rate,pays based on per visit rate,115.02,31.95,,3.376,Fee Schedule,31.95% of LA custom fee schedule,1257.94,2909,
US Pelvis Non-OB Limited ED,3900345,CDM,402,RC,76857,HCPCS,OUTPATIENT,,,360,216,,306,85,,244.8,Percent of total billed charges,85% of total billed charges,184.33,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,184.33,136.6,,16.312,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,115.02,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,59.584,case rate,pays based on per visit rate,115.02,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,1258.94,2910,
US Pregnancy Limited,3900350,CDM,402,RC,76815,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,164.77,136.6,,16.312,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,164.77,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,0.512,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,0.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,23.408,case rate,pays based on per visit rate,129.08,31.95,,0.64,Fee Schedule,31.95% of LA custom fee schedule,1259.94,2911,
US Pregnancy Limited ED,3900350,CDM,402,RC,76815,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,164.77,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,164.77,136.6,,5.096,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,28.624,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,28.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,25.232,case rate,pays based on per visit rate,129.08,31.95,,35.84,Fee Schedule,31.95% of LA custom fee schedule,1260.94,2912,
US Guidance Needle Placement ED,3900355,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,404,242.4,,343.4,85,,274.72,Percent of total billed charges,85% of total billed charges,194.19,136.6,,5.096,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,10.736,fee schedule,35.15% of LA custom fee schedule,129.08,31.95,,10.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,25.232,case rate,pays based on per visit rate,129.08,31.95,,13.44,Fee Schedule,31.95% of LA custom fee schedule,1261.94,2913,
US Guide for CVA,3900360,CDM,402,RC,76937,HCPCS,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,1.78,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,22.752,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,22.752,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,40.736,case rate,pays based on per visit rate,79.88,31.95,,28.48,Fee Schedule,31.95% of LA custom fee schedule,1262.94,2914,
US Guide for CVA ED,3900360,CDM,402,RC,76937,HCPCS,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,1.78,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,336.8,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,77.824,case rate,pays based on per visit rate,79.88,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,1263.94,2915,
US Bladder w/ Residual,3900375,CDM,402,RC,51798,HCPCS,OUTPATIENT,,,305,183,,259.25,85,,207.4,Percent of total billed charges,85% of total billed charges,153.63,136.6,,336.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.63,136.6,,296,fee schedule,136.60% of BCBS custom fee schedule,107.21,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,97.45,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,170.24,case rate,pays based on per visit rate,97.45,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,1264.94,2916,
US Bladder w/ Residual ED,3900375,CDM,402,RC,51798,HCPCS,OUTPATIENT,,,305,183,,259.25,85,,207.4,Percent of total billed charges,85% of total billed charges,153.63,136.6,,296,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.63,136.6,,296,fee schedule,136.60% of BCBS custom fee schedule,107.21,35.15,,9.56,fee schedule,35.15% of LA custom fee schedule,97.45,31.95,,99.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,16.112,case rate,pays based on per visit rate,97.45,31.95,,8.688,Fee Schedule,31.95% of LA custom fee schedule,1265.94,2917,
26011 DRAINAGE FINGER ABSCESS COMPLICATED,3900377,CDM,450,RC,26011,HCPCS,OUTPATIENT,,,3500,2100,,2975,85,,2380,Percent of total billed charges,85% of total billed charges,2921.91,136.6,,296,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2921.91,136.6,,288,fee schedule,136.60% of BCBS custom fee schedule,1118.25,31.95,,7.888,percent of total billed charges,31.95% of total billed charges,1118.25,31.95,,7.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1330,38,,16.112,percent of total billed charges,38% of total billed charges,1400,40,,9.88,percent of total billed charges,40% of total billed charges,1266.94,2918,
CLOSED TX HUMERUS FRACTURE,3900379,CDM,450,RC,24535,HCPCS,OUTPATIENT,,,4386,2631.6,,3728.1,85,,2982.48,Percent of total billed charges,85% of total billed charges,861.18,136.6,,288,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,861.18,136.6,,43.2,fee schedule,136.60% of BCBS custom fee schedule,1401.33,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1401.33,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1666.68,38,,28.36,percent of total billed charges,38% of total billed charges,1754.4,40,,1.92,percent of total billed charges,40% of total billed charges,1267.94,2919,
ECHO TTE F/U OR LIMITED,3900380,CDM,483,RC,93308,HCPCS,OUTPATIENT,,,605,363,,514.25,85,,411.4,Percent of total billed charges,85% of total billed charges,304.77,136.6,,43.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,304.77,136.6,,273.6,fee schedule,136.60% of BCBS custom fee schedule,212.66,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,193.3,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,150,100,,17.632,case rate,pays based on per visit rate,193.3,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,1268.94,2920,
93971 DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY,3900381,CDM,929,RC,93971,HCPCS,OUTPATIENT,,,340,204,,289,85,,231.2,Percent of total billed charges,85% of total billed charges,320.12,136.6,,273.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,119.51,35.15,,0.256,fee schedule,35.15% of LA custom fee schedule,108.63,31.95,,0.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,129.2,38,,17.632,percent of total billed charges,38% of total billed charges,108.63,31.95,,0.32,Fee Schedule,31.95% of LA custom fee schedule,1269.94,2921,
US Guide for CVA ED Professional,3900382,CDM,972,RC,76937,HCPCS,OUTPATIENT,,,73,43.8,26,,,,,other,Not separately reimbursable,,,,80,other,Not separately reimbursable,43.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,96,other,Not separately reimbursable,,,,7.416,other,Not separately reimbursable,,31.95,,7.416,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.712,other,Not separately reimbursable,,,,9.28,other,Not separately reimbursable,1270.94,2922,
36573 INSERTION PICC 5YR+ W/ IMAGING,3900385,CDM,761,RC,36573,HCPCS,OUTPATIENT,,,3281,1968.6,,2788.85,85,,2231.08,Percent of total billed charges,85% of total billed charges,4600.57,136.6,,96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4600.57,136.6,,27.2,fee schedule,136.60% of BCBS custom fee schedule,1048.28,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,1048.28,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,23.712,other,Not separately reimbursable,1312.4,40,,10.24,percent of total billed charges,40% of total billed charges,1271.94,2923,
INSERTION PICC WO PORT 5YR> W/O IMAGING 36569,3900388,CDM,761,RC,36569,HCPCS,OUTPATIENT,,,2190,1314,,1861.5,85,,1489.2,Percent of total billed charges,85% of total billed charges,2060.64,136.6,,27.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2060.64,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,699.71,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,699.71,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,29.488,other,Not separately reimbursable,876,40,,14.08,percent of total billed charges,40% of total billed charges,1272.94,2924,
Conversion Charges:490 - REPOSITION VENOUS CATHETER,3900390,CDM,490,RC,36597,HCPCS,OUTPATIENT,,,3450,2070,,2932.5,85,,2346,Percent of total billed charges,85% of total billed charges,2060.64,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2060.64,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,1102.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1102.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,11.248,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1380,40,,1.28,percent of total billed charges,40% of total billed charges,1273.94,2925,
RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP,3900391,CDM,450,RC,36581,HCPCS,OUTPATIENT,,,7000,4200,,5950,85,,4760,Percent of total billed charges,85% of total billed charges,5318.89,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5318.89,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,2236.5,31.95,,3.656,percent of total billed charges,31.95% of total billed charges,2236.5,31.95,,3.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2660,38,,6.688,percent of total billed charges,38% of total billed charges,2800,40,,4.576,percent of total billed charges,40% of total billed charges,1274.94,2926,
36584 REPLACEMENT PICC W/IMAGING,3900392,CDM,761,RC,36584,HCPCS,OUTPATIENT,,,3281,1968.6,,2788.85,85,,2231.08,Percent of total billed charges,85% of total billed charges,2060.64,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2060.64,136.6,,26,fee schedule,136.60% of BCBS custom fee schedule,1048.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,1048.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,6.688,other,Not separately reimbursable,1312.4,40,,3.84,percent of total billed charges,40% of total billed charges,1275.94,2927,
Non-routine bl draw 3/> yrs,3900393,CDM,761,RC,36410,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,1.78,136.6,,26,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,12.3,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,4.56,other,Not separately reimbursable,11.18,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,1276.94,2928,
52005 CYSTOSCOPY  URETER CATHETER,3900395,CDM,490,RC,52005,HCPCS,OUTPATIENT,,,6576,3945.6,,5589.6,85,,4471.68,Percent of total billed charges,85% of total billed charges,4651.49,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4651.49,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,529.4,110,,3.064,fee schedule,110% of Asc Tier Grouping Fee Schedule,481.27,100,,3.064,fee schedule,100% of Asc Tier Grouping Fee Schedule,,,,,other,Not separately reimbursable,1450,100,,6.688,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,481.27,100,,3.84,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1277.94,2929,
36593 DECLOT VASCULAR DEVICE,3900396,CDM,761,RC,36593,HCPCS,OUTPATIENT,,,865,519,,735.25,85,,588.2,Percent of total billed charges,85% of total billed charges,207.24,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,207.24,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,304.05,35.15,,3.832,fee schedule,35.15% of LA custom fee schedule,276.37,31.95,,3.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,9.728,other,Not separately reimbursable,276.37,31.95,,4.8,Fee Schedule,31.95% of LA custom fee schedule,1278.94,2930,
54220 TREATMENT OF PENIS LESION,3900398,CDM,490,RC,54220,HCPCS,OUTPATIENT,,,864,518.4,,734.4,85,,587.52,Percent of total billed charges,85% of total billed charges,653.96,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,653.96,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,395.29,110,,3.824,fee schedule,110% of Asc Tier Grouping Fee Schedule,359.35,100,,3.824,fee schedule,100% of Asc Tier Grouping Fee Schedule,,,,,other,Not separately reimbursable,385,100,,8.208,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,359.35,100,,4.784,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1279.94,2931,
US Guided Abd Paracentesis,3900400,CDM,320,RC,49083,HCPCS,OUTPATIENT,,,1941,1164.6,TC,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1621.77,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1621.77,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,682.26,35.15,,3.448,fee schedule,35.15% of LA custom fee schedule,620.15,31.95,,3.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,19.456,case rate,pays based on per visit rate,620.15,31.95,,4.32,Fee Schedule,31.95% of LA custom fee schedule,1280.94,2932,
US Guided Abd Paracentesis,3900400,CDM,402,RC,49083,HCPCS,OUTPATIENT,,,1941,1164.6,TC,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1621.77,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1621.77,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,682.26,35.15,,3.448,fee schedule,35.15% of LA custom fee schedule,620.15,31.95,,3.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,22.192,case rate,pays based on per visit rate,620.15,31.95,,4.32,Fee Schedule,31.95% of LA custom fee schedule,1281.94,2933,
49083 Abd Paracentesis w/imaging,3900400,CDM,490,RC,49083,HCPCS,OUTPATIENT,,,1941,1164.6,TC,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1621.77,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1621.77,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,620.15,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,620.15,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,41.952,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,776.4,40,,4.32,percent of total billed charges,40% of total billed charges,1282.94,2934,
43753 TX GASTRO INTUB W/ASP,3900401,CDM,490,RC,43753,HCPCS,OUTPATIENT,,,929,557.4,,789.65,85,,631.72,Percent of total billed charges,85% of total billed charges,194.46,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.46,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,296.82,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,296.82,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,49.248,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,371.6,40,,4.32,percent of total billed charges,40% of total billed charges,1283.94,2935,
67715 INCISION OF EYELID FOLD,3900402,CDM,490,RC,67715,HCPCS,OUTPATIENT,,,6800,4080,,5780,85,,4624,Percent of total billed charges,85% of total billed charges,4511.02,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4511.02,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,395.29,110,,3.448,fee schedule,110% of Asc Tier Grouping Fee Schedule,359.35,100,,3.448,fee schedule,100% of Asc Tier Grouping Fee Schedule,,,,,other,Not separately reimbursable,1450,100,,4.56,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,359.35,100,,4.32,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1284.94,2936,
DRAINAGE ABSCESS PALATE UVULA,3900410,CDM,450,RC,42000,HCPCS,OUTPATIENT,,,610,366,,518.5,85,,414.8,Percent of total billed charges,85% of total billed charges,520.43,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,520.43,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,194.9,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,194.9,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,231.8,38,,14.896,percent of total billed charges,38% of total billed charges,244,40,,2.88,percent of total billed charges,40% of total billed charges,1285.94,2937,
REPAIR BLOOD VESSEL DIRECT NECK,3900431,CDM,490,RC,35201,HCPCS,OUTPATIENT,,,8200,4920,,6970,85,,5576,Percent of total billed charges,85% of total billed charges,5835.54,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5835.54,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,2619.9,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2619.9,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5000,100,,14.896,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,3280,40,,2.88,percent of total billed charges,40% of total billed charges,1286.94,2938,
VASCULAR SURGERY PROCEDURE UNLISTED,3900449,CDM,490,RC,37799,HCPCS,OUTPATIENT,,,1880,1128,,1598,85,,1278.4,Percent of total billed charges,85% of total billed charges,3765.86,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3765.86,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,600.66,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,600.66,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,25.84,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,752,40,,2.88,percent of total billed charges,40% of total billed charges,1287.94,2939,
APPLICATON ON-BODY INJECTOR,3900477,CDM,450,RC,96377,HCPCS,OUTPATIENT,,,105,63,59,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,128.28,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,128.28,136.6,,37.6,fee schedule,136.60% of BCBS custom fee schedule,36.91,35.15,,2.56,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.9,38,,25.84,percent of total billed charges,38% of total billed charges,33.55,31.95,,3.2,percent of total billed charges,31.95% of total billed charges,1288.94,2940,
Cryo AHF,3938362,CDM,387,RC,P9012,HCPCS,OUTPATIENT,,,262,157.2,,222.7,85,,178.16,Percent of total billed charges,85% of total billed charges,131,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,131,50,,4.8,percent of total billed charges,50% of total billed charges,92.09,35.15,,3.448,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,31.92,case rate,pays based on per visit rate,83.71,31.95,,4.32,percent of total billed charges,31.95% of total billed charges,1289.94,2941,
Thawed Cryo AHF,3938362,CDM,387,RC,P9012,HCPCS,OUTPATIENT,,,262,157.2,,222.7,85,,178.16,Percent of total billed charges,85% of total billed charges,131,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,131,50,,37.6,percent of total billed charges,50% of total billed charges,92.09,35.15,,2.304,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,31.92,case rate,pays based on per visit rate,83.71,31.95,,2.88,percent of total billed charges,31.95% of total billed charges,1290.94,2942,
Pooled Cryo <18C 5 units,3938362,CDM,387,RC,P9012,HCPCS,OUTPATIENT,,,262,157.2,,222.7,85,,178.16,Percent of total billed charges,85% of total billed charges,131,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,131,50,,10.8,percent of total billed charges,50% of total billed charges,92.09,35.15,,51.632,percent of total billed charges,35.15% of total billed charges,1155.63,31.95,,51.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,138.016,case rate,pays based on per visit rate,83.71,31.95,,64.64,percent of total billed charges,31.95% of total billed charges,1291.94,2943,
Thawed Pooled Cryo Open 5 units,3938362,CDM,387,RC,P9012,HCPCS,OUTPATIENT,,,262,157.2,,222.7,85,,178.16,Percent of total billed charges,85% of total billed charges,131,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,131,50,,37.6,percent of total billed charges,50% of total billed charges,92.09,35.15,,3.32,percent of total billed charges,35.15% of total billed charges,1176.4,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,21.584,case rate,pays based on per visit rate,83.71,31.95,,4.16,percent of total billed charges,31.95% of total billed charges,1292.94,2944,
Thawed Pooled Cryo Open 10 units,3938362,CDM,387,RC,P9012,HCPCS,OUTPATIENT,,,262,157.2,,222.7,85,,178.16,Percent of total billed charges,85% of total billed charges,131,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,131,50,,5.4,percent of total billed charges,50% of total billed charges,92.09,35.15,,12.656,percent of total billed charges,35.15% of total billed charges,1236.47,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,21.584,case rate,pays based on per visit rate,83.71,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,1293.94,2945,
FFP Thawed CPD,3938446,CDM,383,RC,P9017,HCPCS,OUTPATIENT,,,385,231,,327.25,85,,261.8,Percent of total billed charges,85% of total billed charges,192.5,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,192.5,50,,36,percent of total billed charges,50% of total billed charges,135.33,35.15,,0.512,percent of total billed charges,35.15% of total billed charges,1262.03,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,15.2,case rate,pays based on per visit rate,123.01,31.95,,0.64,percent of total billed charges,31.95% of total billed charges,1294.94,2946,
Aph FFP ACDA Dv Thawed,3938446,CDM,383,RC,P9017,HCPCS,OUTPATIENT,,,385,231,,327.25,85,,261.8,Percent of total billed charges,85% of total billed charges,192.5,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,192.5,50,,8.8,percent of total billed charges,50% of total billed charges,135.33,35.15,,0.512,percent of total billed charges,35.15% of total billed charges,1263.62,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,98.496,case rate,pays based on per visit rate,123.01,31.95,,0.64,percent of total billed charges,31.95% of total billed charges,1295.94,2947,
Aph FFP ACDA Thawed,3938446,CDM,383,RC,P9017,HCPCS,OUTPATIENT,,,385,231,,327.25,85,,261.8,Percent of total billed charges,85% of total billed charges,192.5,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,192.5,50,,36,percent of total billed charges,50% of total billed charges,135.33,35.15,,1.28,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,13.68,case rate,pays based on per visit rate,123.01,31.95,,1.6,percent of total billed charges,31.95% of total billed charges,1296.94,2948,
Aph Plasma ACDA <24 Hrs Thawed Dv,3938446,CDM,383,RC,P9017,HCPCS,OUTPATIENT,,,385,231,,327.25,85,,261.8,Percent of total billed charges,85% of total billed charges,192.5,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,192.5,50,,7.2,percent of total billed charges,50% of total billed charges,135.33,35.15,,1.28,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,31.008,case rate,pays based on per visit rate,123.01,31.95,,1.6,percent of total billed charges,31.95% of total billed charges,1297.94,2949,
Thawed Plasma CPD <24h,3938446,CDM,383,RC,P9017,HCPCS,OUTPATIENT,,,385,231,,327.25,85,,261.8,Percent of total billed charges,85% of total billed charges,192.5,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,192.5,50,,36,percent of total billed charges,50% of total billed charges,135.33,35.15,,8.176,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,16.72,case rate,pays based on per visit rate,123.01,31.95,,10.24,percent of total billed charges,31.95% of total billed charges,1298.94,2950,
Thawed Aph FFP ACDA 200-400 mL,3938447,CDM,383,RC,P9017,HCPCS,OUTPATIENT,,,385,231,,327.25,85,,261.8,Percent of total billed charges,85% of total billed charges,192.5,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,192.5,50,,4.6,percent of total billed charges,50% of total billed charges,135.33,35.15,,7.416,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,4.56,case rate,pays based on per visit rate,123.01,31.95,,9.28,percent of total billed charges,31.95% of total billed charges,1299.94,2951,
Thawing Fee,3964327,CDM,300,RC,86927,HCPCS,OUTPATIENT,,,542,325.2,,460.7,85,,368.56,Percent of total billed charges,85% of total billed charges,20.34,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.34,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,12.16,110,,7.416,fee schedule,110% of LA custom fee schedule,11.05,100,,7.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,205.96,38,,31.616,percent of total billed charges,38% of total billed charges,11.05,100,,9.28,Fee Schedule,100% of LA custom fee schedule,1300.94,2952,
RBC CP2D AS3 500 LR,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,27.096,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,27.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,46.816,case rate,pays based on per visit rate,186.91,31.95,,33.92,percent of total billed charges,31.95% of total billed charges,1301.94,2953,
RBC CPD AS1 500,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,2.528,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,12.16,case rate,pays based on per visit rate,186.91,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,1302.94,2954,
RBC CPD AS1 500 LR,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,2.304,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,23.104,case rate,pays based on per visit rate,186.91,31.95,,2.88,percent of total billed charges,31.95% of total billed charges,1303.94,2955,
Aph RBC ACDA AS1,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,2.304,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,19.76,case rate,pays based on per visit rate,186.91,31.95,,2.88,percent of total billed charges,31.95% of total billed charges,1304.94,2956,
Aph RBC ACDA AS1 LR,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,2.304,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,19.76,case rate,pays based on per visit rate,186.91,31.95,,2.88,percent of total billed charges,31.95% of total billed charges,1305.94,2957,
Aph RBC ACDA AS3 LR,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,0.256,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,10.64,case rate,pays based on per visit rate,186.91,31.95,,0.32,percent of total billed charges,31.95% of total billed charges,1306.94,2958,
Aph RBC ACDA AS3 LR 1,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,0.768,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,10.64,case rate,pays based on per visit rate,186.91,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,1307.94,2959,
Aph RBC ACDA AS3 LR 2,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,1.28,percent of total billed charges,35.15% of total billed charges,96.81,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,27.968,case rate,pays based on per visit rate,186.91,31.95,,1.6,percent of total billed charges,31.95% of total billed charges,1308.94,2960,
Aph RBC ACDA AS1 LR 1,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,1.024,percent of total billed charges,35.15% of total billed charges,97.13,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,26.752,case rate,pays based on per visit rate,186.91,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1309.94,2961,
Aph RBC ACDA AS1 LR 2,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,13.8,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,13.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,19.76,case rate,pays based on per visit rate,186.91,31.95,,17.28,percent of total billed charges,31.95% of total billed charges,1310.94,2962,
RBC CPD AS1 500 LR DV,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,15.744,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,13.68,case rate,pays based on per visit rate,186.91,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,1311.94,2963,
E5157 RBC CPD AS1 LowV,3990165,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,15.744,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,15.2,case rate,pays based on per visit rate,186.91,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,1312.94,2964,
Aph Plt ACDA LR,3990348,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,15.744,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,27.056,case rate,pays based on per visit rate,439.63,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,1313.94,2965,
Aph Plt ACDA LR 1,3990348,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,15.744,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,10.336,case rate,pays based on per visit rate,439.63,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,1314.94,2966,
Aph Plt ACDA LR 2,3990348,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,15.744,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,10.336,case rate,pays based on per visit rate,439.63,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,1315.94,2967,
EA008 Aph Plt ACDA LR BM>=36h 1,3990348,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,3.8,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,2.744,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,2.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,10.336,case rate,pays based on per visit rate,439.63,31.95,,3.44,percent of total billed charges,31.95% of total billed charges,1316.94,2968,
RBC CPD AS1 500 LR Irr,3990350,CDM,381,RC,P9038,HCPCS,OUTPATIENT,,,1030,618,,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,515,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,515,50,,45.2,percent of total billed charges,50% of total billed charges,362.05,35.15,,1.792,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,12.464,case rate,pays based on per visit rate,329.09,31.95,,2.24,percent of total billed charges,31.95% of total billed charges,1317.94,2969,
Aph RBC ACDA AS1 LR Irr,3990352,CDM,381,RC,P9038,HCPCS,OUTPATIENT,,,1030,618,,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,515,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,515,50,,6,percent of total billed charges,50% of total billed charges,362.05,35.15,,1.968,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,100.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,25.232,case rate,pays based on per visit rate,329.09,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,1318.94,2970,
RBC CPD AS5 500 LR,3990355,CDM,381,RC,P9038,HCPCS,OUTPATIENT,,,1030,618,,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,515,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,515,50,,45.2,percent of total billed charges,50% of total billed charges,362.05,35.15,,1.792,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,11.856,case rate,pays based on per visit rate,329.09,31.95,,2.24,percent of total billed charges,31.95% of total billed charges,1319.94,2971,
Aph Plt ACDA LR Irr 1,3990358,CDM,384,RC,P9036,HCPCS,OUTPATIENT,,,2225,1335,,1891.25,85,,1513,Percent of total billed charges,85% of total billed charges,1112.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1112.5,50,,3.8,percent of total billed charges,50% of total billed charges,782.09,35.15,,2.696,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,2.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,22.304,case rate,pays based on per visit rate,710.89,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,1320.94,2972,
Aph RBC ACDA AS1 LR Irr 1,3990359,CDM,381,RC,P9038,HCPCS,OUTPATIENT,,,1030,618,,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,515,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,515,50,,3.8,percent of total billed charges,50% of total billed charges,362.05,35.15,,1.536,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,13.984,case rate,pays based on per visit rate,329.09,31.95,,1.92,percent of total billed charges,31.95% of total billed charges,1321.94,2973,
Aph RBC ACDA AS1 LR Irr 2,3990360,CDM,381,RC,P9038,HCPCS,OUTPATIENT,,,1030,618,,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,515,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,515,50,,6.8,percent of total billed charges,50% of total billed charges,362.05,35.15,,2.304,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,11.552,case rate,pays based on per visit rate,329.09,31.95,,2.88,percent of total billed charges,31.95% of total billed charges,1322.94,2974,
Aph Plt ACDA LR Irr 2,3990361,CDM,384,RC,P9033,HCPCS,OUTPATIENT,,,1030,618,,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,515,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,515,50,,4.6,percent of total billed charges,50% of total billed charges,362.05,35.15,,2.304,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,29.184,case rate,pays based on per visit rate,329.09,31.95,,2.88,percent of total billed charges,31.95% of total billed charges,1323.94,2975,
Aph Plt ACDA LR Irr,3990362,CDM,384,RC,P9033,HCPCS,OUTPATIENT,,,1030,618,,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,515,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,515,50,,4.6,percent of total billed charges,50% of total billed charges,362.05,35.15,,7.672,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,29.184,case rate,pays based on per visit rate,329.09,31.95,,9.6,percent of total billed charges,31.95% of total billed charges,1324.94,2976,
Aph Plt ACDA LR 3,3990363,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,7.4,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,7.672,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,22.192,case rate,pays based on per visit rate,439.63,31.95,,9.6,percent of total billed charges,31.95% of total billed charges,1325.94,2977,
RBC CPD AS1 450 LR Irr,3990364,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,7.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,7.672,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,58.672,case rate,pays based on per visit rate,439.63,31.95,,9.6,percent of total billed charges,31.95% of total billed charges,1326.94,2978,
RBC CPD AS1 450,3990367,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,4.2,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,24.536,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,34.048,case rate,pays based on per visit rate,186.91,31.95,,30.72,percent of total billed charges,31.95% of total billed charges,1327.94,2979,
RBC CPD AS1 450 LR,3990367,CDM,381,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,4.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,23.512,percent of total billed charges,35.15% of total billed charges,98.41,31.95,,23.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,11.384,case rate,pays based on per visit rate,186.91,31.95,,29.44,percent of total billed charges,31.95% of total billed charges,1328.94,2980,
Aph Plt ACDA PASC LR Cnt 3,3990369,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,6.2,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,78.728,percent of total billed charges,35.15% of total billed charges,98.73,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,11.736,case rate,pays based on per visit rate,439.63,31.95,,98.56,percent of total billed charges,31.95% of total billed charges,1329.94,2981,
Aph Plt ACDA PASC LR Cnt 2,3990371,CDM,384,RC,P9034,HCPCS,OUTPATIENT,,,1376,825.6,,1169.6,85,,935.68,Percent of total billed charges,85% of total billed charges,985.19,136.6,,6.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,985.19,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,483.66,35.15,,28.984,percent of total billed charges,35.15% of total billed charges,98.73,31.95,,28.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,71.136,case rate,pays based on per visit rate,439.63,31.95,,36.288,percent of total billed charges,31.95% of total billed charges,1330.94,2982,
RT Pre/Post Spirometry,4000001,CDM,460,RC,94060,HCPCS,OUTPATIENT,,,450,270,TC,382.5,85,,306,Percent of total billed charges,85% of total billed charges,192.85,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,192.85,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,1.536,fee schedule,35.15% of LA custom fee schedule,143.78,31.95,,1.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,7.6,case rate,pays based on per visit rate,143.78,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,1331.94,2983,
PROF Pre/Post Spirometry,4000001,CDM,976,RC,94060,HCPCS,OUTPATIENT,,,31,18.6,TC,,,,,other,Not separately reimbursable,,,,8.4,other,Not separately reimbursable,77.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,8.4,other,Not separately reimbursable,,,,14.824,other,Not separately reimbursable,,31.95,,14.824,other,Not separately reimbursable,25.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,40.736,other,Not separately reimbursable,,,,18.56,other,Not separately reimbursable,1332.94,2984,
Nasotrachael Suction,4000002,CDM,410,RC,31720,HCPCS,OUTPATIENT,,,235,141,,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,201.12,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,201.12,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,75.08,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,75.08,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,140,100,,8.816,case rate,pays based on per visit rate,94,40,,12.16,percent of total billed charges,40% of total billed charges,1333.94,2985,
Pulse Oximetry Continuous,4000003,CDM,410,RC,94762,HCPCS,OUTPATIENT,,,394,236.4,,334.9,85,,267.92,Percent of total billed charges,85% of total billed charges,1.78,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,138.49,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,125.88,31.95,,100.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,18.24,case rate,pays based on per visit rate,125.88,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,1334.94,2986,
Incentive Spirometry Subsequent,4000003,CDM,460,RC,94200,HCPCS,OUTPATIENT,,,173,103.8,,147.05,85,,117.64,Percent of total billed charges,85% of total billed charges,131.78,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,131.78,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,60.81,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,55.27,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,8.208,case rate,pays based on per visit rate,55.27,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,1335.94,2987,
Pulse Oximetry Cont RT,4000003,CDM,410,RC,94762,HCPCS,OUTPATIENT,,,394,236.4,,334.9,85,,267.92,Percent of total billed charges,85% of total billed charges,1.78,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,138.49,35.15,,15.848,fee schedule,35.15% of LA custom fee schedule,125.88,31.95,,15.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,7.904,case rate,pays based on per visit rate,125.88,31.95,,19.84,Fee Schedule,31.95% of LA custom fee schedule,1336.94,2988,
Pulse Oximetry Continuous,4000003,CDM,410,RC,94762,HCPCS,OUTPATIENT,,,394,236.4,,334.9,85,,267.92,Percent of total billed charges,85% of total billed charges,1.78,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,138.49,35.15,,2.808,fee schedule,35.15% of LA custom fee schedule,125.88,31.95,,2.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,8.816,case rate,pays based on per visit rate,125.88,31.95,,3.52,Fee Schedule,31.95% of LA custom fee schedule,1337.94,2989,
BiPAP/CPAP Initial,4000004,CDM,410,RC,94002,HCPCS,OUTPATIENT,,,1048,628.8,,890.8,85,,712.64,Percent of total billed charges,85% of total billed charges,451.65,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,451.65,136.6,,7.4,fee schedule,136.60% of BCBS custom fee schedule,368.37,35.15,,2.808,fee schedule,35.15% of LA custom fee schedule,334.84,31.95,,2.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,13.68,case rate,pays based on per visit rate,334.84,31.95,,3.52,Fee Schedule,31.95% of LA custom fee schedule,1338.94,2990,
BiPAP/CPAP Subsequent,4000004,CDM,410,RC,94660,HCPCS,OUTPATIENT,,,1048,628.8,,890.8,85,,712.64,Percent of total billed charges,85% of total billed charges,250.62,136.6,,7.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.62,136.6,,6.6,fee schedule,136.60% of BCBS custom fee schedule,368.37,35.15,,2.808,fee schedule,35.15% of LA custom fee schedule,334.84,31.95,,2.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,35.872,case rate,pays based on per visit rate,334.84,31.95,,3.52,Fee Schedule,31.95% of LA custom fee schedule,1339.94,2991,
"POX, Single Determination Charge",4000004,CDM,460,RC,94761,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,1.78,136.6,,6.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,43.94,35.15,,19.936,fee schedule,35.15% of LA custom fee schedule,39.94,31.95,,19.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,33.376,case rate,pays based on per visit rate,39.94,31.95,,24.96,Fee Schedule,31.95% of LA custom fee schedule,1340.94,2992,
"POX, Multiple Determination Charge",4000005,CDM,460,RC,94761,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,1.78,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,7.4,fee schedule,136.60% of BCBS custom fee schedule,43.94,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,39.94,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,31.616,case rate,pays based on per visit rate,39.94,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,1341.94,2993,
CPT Initial  RT Charge,4000006,CDM,410,RC,94667,HCPCS,OUTPATIENT,,,235,141,,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,69.09,136.6,,7.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,82.6,35.15,,3.832,fee schedule,35.15% of LA custom fee schedule,75.08,31.95,,3.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,6.384,case rate,pays based on per visit rate,75.08,31.95,,4.8,Fee Schedule,31.95% of LA custom fee schedule,1342.94,2994,
RT Peak Flow Procedure Charge,4000006,CDM,460,RC,94150,HCPCS,OUTPATIENT,,,173,103.8,,147.05,85,,117.64,Percent of total billed charges,85% of total billed charges,131.78,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,131.78,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,60.81,35.15,,9.56,fee schedule,35.15% of LA custom fee schedule,55.27,31.95,,9.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,6.384,case rate,pays based on per visit rate,55.27,31.95,,11.968,Fee Schedule,31.95% of LA custom fee schedule,1343.94,2995,
RT Pulse Oximetry; Single Day Charge,4000007,CDM,460,RC,94761,HCPCS,OUTPATIENT,,,55,33,59,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,1.78,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,19.33,35.15,,3.576,fee schedule,35.15% of LA custom fee schedule,17.57,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,6.384,case rate,pays based on per visit rate,17.57,31.95,,4.48,Fee Schedule,31.95% of LA custom fee schedule,1344.94,2996,
CPT Subsequent,4000007,CDM,410,RC,94668,HCPCS,OUTPATIENT,,,119,71.4,59,101.15,85,,80.92,Percent of total billed charges,85% of total billed charges,69.09,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,41.83,35.15,,11.352,fee schedule,35.15% of LA custom fee schedule,38.02,31.95,,11.352,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,6.384,case rate,pays based on per visit rate,38.02,31.95,,14.208,Fee Schedule,31.95% of LA custom fee schedule,1345.94,2997,
RT Spirometry w/Graphic Record,4000008,CDM,460,RC,94010,HCPCS,OUTPATIENT,,,242,145.2,TC,205.7,85,,164.56,Percent of total billed charges,85% of total billed charges,192.85,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,192.85,136.6,,6.6,fee schedule,136.60% of BCBS custom fee schedule,85.06,35.15,,5.624,fee schedule,35.15% of LA custom fee schedule,77.32,31.95,,5.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,6.384,case rate,pays based on per visit rate,77.32,31.95,,7.04,Fee Schedule,31.95% of LA custom fee schedule,1346.94,2998,
PROF RT Spirometry w/Graphic Record,4000008,CDM,976,RC,94010,HCPCS,OUTPATIENT,,,25,15,TC,,,,,other,Not separately reimbursable,,,,6.6,other,Not separately reimbursable,46.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,8.6,other,Not separately reimbursable,,,,1.024,other,Not separately reimbursable,,31.95,,1.024,other,Not separately reimbursable,17.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.6,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,1347.94,2999,
Aerosol Initial,4000010,CDM,410,RC,94640,HCPCS,OUTPATIENT,,,235,141,,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,69.09,136.6,,8.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,82.6,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,75.08,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,6.384,case rate,pays based on per visit rate,75.08,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,1348.94,3000,
Aerosol Subsequent,4000010,CDM,410,RC,94640,HCPCS,OUTPATIENT,,,235,141,,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,69.09,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,7,fee schedule,136.60% of BCBS custom fee schedule,82.6,35.15,,17.224,fee schedule,35.15% of LA custom fee schedule,75.08,31.95,,17.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,32.832,case rate,pays based on per visit rate,75.08,31.95,,21.56,Fee Schedule,31.95% of LA custom fee schedule,1349.94,3001,
Aerosol Initial,4000010,CDM,410,RC,94640,HCPCS,OUTPATIENT,,,235,141,,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,69.09,136.6,,7,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,82.6,35.15,,17.224,fee schedule,35.15% of LA custom fee schedule,75.08,31.95,,17.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,32.832,case rate,pays based on per visit rate,75.08,31.95,,21.56,Fee Schedule,31.95% of LA custom fee schedule,1350.94,3002,
Pulmonary Stress Test,4000011,CDM,460,RC,94621,HCPCS,OUTPATIENT,,,731,438.6,,621.35,85,,497.08,Percent of total billed charges,85% of total billed charges,545.1,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,545.1,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,256.95,35.15,,17.224,fee schedule,35.15% of LA custom fee schedule,233.55,31.95,,17.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,24.32,case rate,pays based on per visit rate,233.55,31.95,,21.56,Fee Schedule,31.95% of LA custom fee schedule,1351.94,3003,
Exercise test for bronchospasm,4000012,CDM,410,RC,94617,HCPCS,OUTPATIENT,,,420,252,,357,85,,285.6,Percent of total billed charges,85% of total billed charges,192.85,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,192.85,136.6,,7,fee schedule,136.60% of BCBS custom fee schedule,147.63,35.15,,17.384,fee schedule,35.15% of LA custom fee schedule,134.19,31.95,,17.384,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,58.368,case rate,pays based on per visit rate,134.19,31.95,,21.76,Fee Schedule,31.95% of LA custom fee schedule,1352.94,3004,
G0237 THER PROC STRGTH/ENDUR EA 15 MIN,4000013,CDM,410,RC,G0237,HCPCS,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,79.05,136.6,,7,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.05,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,41.48,35.15,,3.576,percent of total billed charges,35.15% of total billed charges,98.73,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,140,100,,37.88,case rate,pays based on per visit rate,37.7,31.95,,4.48,percent of total billed charges,31.95% of total billed charges,1353.94,3005,
Pulmonary stress testing,4000014,CDM,410,RC,94618,HCPCS,OUTPATIENT,,,420,252,,357,85,,285.6,Percent of total billed charges,85% of total billed charges,192.85,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,192.85,136.6,,6.6,fee schedule,136.60% of BCBS custom fee schedule,147.63,35.15,,7.264,fee schedule,35.15% of LA custom fee schedule,134.19,31.95,,7.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,33.44,case rate,pays based on per visit rate,134.19,31.95,,9.088,Fee Schedule,31.95% of LA custom fee schedule,1354.94,3006,
UPR/L XTREMITY ART 2 LEVELS,4000015,CDM,920,RC,93922,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,322.9,136.6,,6.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,322.9,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,79.09,35.15,,17.224,fee schedule,35.15% of LA custom fee schedule,71.89,31.95,,17.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,85.5,38,,11.248,percent of total billed charges,38% of total billed charges,71.89,31.95,,21.56,Fee Schedule,31.95% of LA custom fee schedule,1355.94,3007,
LIMITED EXTREMITY ANALYSIS REPORT,4000015,CDM,972,RC,93922,HCPCS,OUTPATIENT,,,40,24,,,,,,other,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,107.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,4.6,other,Not separately reimbursable,,,,17.384,other,Not separately reimbursable,,31.95,,17.384,other,Not separately reimbursable,40,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,21.76,other,Not separately reimbursable,1356.94,3008,
LIMITED EXTREMITY ANALYSIS,4000015,CDM,920,RC,93922,HCPCS,OUTPATIENT,,,190,114,,161.5,85,,129.2,Percent of total billed charges,85% of total billed charges,322.9,136.6,,4.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,322.9,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,66.79,35.15,,10.224,fee schedule,35.15% of LA custom fee schedule,60.71,31.95,,10.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,72.2,38,,71.744,percent of total billed charges,38% of total billed charges,60.71,31.95,,12.8,Fee Schedule,31.95% of LA custom fee schedule,1357.94,3009,
Trach Care,4000016,CDM,270,RC,,,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,27.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.5,50,,9.4,percent of total billed charges,50% of total billed charges,17.57,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.9,38,,9.424,percent of total billed charges,38% of total billed charges,22,40,,2.24,percent of total billed charges,40% of total billed charges,1358.94,3010,
G0238 THERPROCRESPFUNCTIONINDIVEA15M,4000018,CDM,410,RC,G0238,HCPCS,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,79.05,136.6,,9.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.05,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,41.48,35.15,,3.832,percent of total billed charges,35.15% of total billed charges,99.05,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,140,100,,16.72,case rate,pays based on per visit rate,37.7,31.95,,4.8,percent of total billed charges,31.95% of total billed charges,1359.94,3011,
G0239 THERPROCRESPSTRENGTH/FUNCTION2+,4000019,CDM,410,RC,G0239,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,79.05,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.05,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,43.94,35.15,,20.192,percent of total billed charges,35.15% of total billed charges,100.64,31.95,,20.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,140,100,,43.864,case rate,pays based on per visit rate,39.94,31.95,,25.28,percent of total billed charges,31.95% of total billed charges,1360.94,3012,
Carboxyhemoglobin Reference Test,4000020,CDM,301,RC,82375,HCPCS,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,57.47,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.47,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,13.55,110,,14.824,fee schedule,110% of LA custom fee schedule,12.32,100,,14.824,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.06,38,,44.472,percent of total billed charges,38% of total billed charges,12.32,100,,18.56,Fee Schedule,100% of LA custom fee schedule,1361.94,3013,
Carboxyhemoglobin,4000020,CDM,301,RC,82375,HCPCS,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,57.47,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.47,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,13.55,110,,23.256,fee schedule,110% of LA custom fee schedule,12.32,100,,23.256,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.06,38,,36.48,percent of total billed charges,38% of total billed charges,12.32,100,,29.12,Fee Schedule,100% of LA custom fee schedule,1362.94,3014,
Incentive Spirometry Initial,4000023,CDM,460,RC,94200,HCPCS,OUTPATIENT,,,173,103.8,,147.05,85,,117.64,Percent of total billed charges,85% of total billed charges,131.78,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,131.78,136.6,,680,fee schedule,136.60% of BCBS custom fee schedule,60.81,35.15,,12.288,fee schedule,35.15% of LA custom fee schedule,55.27,31.95,,12.288,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,33.44,case rate,pays based on per visit rate,55.27,31.95,,15.392,Fee Schedule,31.95% of LA custom fee schedule,1363.94,3015,
INCISION  DRAINAGE ABSCESS SIMPLE/SINGLE,4000025,CDM,761,RC,10060,HCPCS,OUTPATIENT,,,472,283.2,,401.2,85,,320.96,Percent of total billed charges,85% of total billed charges,495.68,136.6,,680,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,150.8,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,150.8,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,8.208,other,Not separately reimbursable,188.8,40,,7.36,percent of total billed charges,40% of total billed charges,1364.94,3016,
PROF PULM FUNCT TEST PLETHYSMOGRAPHY,4000026,CDM,976,RC,94726,HCPCS,OUTPATIENT,,,36,21.6,26,,,,,other,Not separately reimbursable,,,,8.8,other,Not separately reimbursable,69.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,8.4,other,Not separately reimbursable,,,,6.024,other,Not separately reimbursable,,31.95,,6.024,other,Not separately reimbursable,36,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.528,other,Not separately reimbursable,,,,7.536,other,Not separately reimbursable,1365.94,3017,
PULM FUNCT TEST PLETHYSMOGRAPHY,4000026,CDM,460,RC,94726,HCPCS,OUTPATIENT,,,450,270,26,382.5,85,,306,Percent of total billed charges,85% of total billed charges,175.95,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,175.95,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,5.368,fee schedule,35.15% of LA custom fee schedule,143.78,31.95,,5.368,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,15.528,case rate,pays based on per visit rate,143.78,31.95,,6.72,Fee Schedule,31.95% of LA custom fee schedule,1366.94,3018,
PULM FUNCT TEST PLETHYSMOGRAPHY,4000026,CDM,460,RC,94726,HCPCS,OUTPATIENT,,,450,270,26,382.5,85,,306,Percent of total billed charges,85% of total billed charges,175.95,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,175.95,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,3.576,fee schedule,35.15% of LA custom fee schedule,143.78,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,28.88,case rate,pays based on per visit rate,143.78,31.95,,4.48,Fee Schedule,31.95% of LA custom fee schedule,1367.94,3019,
PROF CO MEMBRANE DIFFUSING CAPACITY,4000029,CDM,976,RC,94729,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,2.8,other,Not separately reimbursable,71.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,16.8,other,Not separately reimbursable,,,,4.088,other,Not separately reimbursable,,31.95,,4.088,other,Not separately reimbursable,27,100,,,fee schedule,100% of CMS physician fee schedule,,,,28.88,other,Not separately reimbursable,,,,5.12,other,Not separately reimbursable,1368.94,3020,
CO MEMBRANE DIFFUSING CAPACITY,4000029,CDM,460,RC,94729,HCPCS,OUTPATIENT,,,360,216,26,306,85,,244.8,Percent of total billed charges,85% of total billed charges,211.18,136.6,,16.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,211.18,136.6,,558.8,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,9.56,fee schedule,35.15% of LA custom fee schedule,115.02,31.95,,100.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,77.824,case rate,pays based on per visit rate,115.02,31.95,,8.688,Fee Schedule,31.95% of LA custom fee schedule,1369.94,3021,
PULMONARY FUNCTION TEST CO MEMBRANE DIFFUSING CAPACITY,4000029,CDM,460,RC,94729,HCPCS,OUTPATIENT,,,360,216,26,306,85,,244.8,Percent of total billed charges,85% of total billed charges,211.18,136.6,,558.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,211.18,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,9.56,fee schedule,35.15% of LA custom fee schedule,115.02,31.95,,100.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,24.32,case rate,pays based on per visit rate,115.02,31.95,,8.688,Fee Schedule,31.95% of LA custom fee schedule,1370.94,3022,
PFT CO MEMBRANE DIFFUSING CAPACITY FMC,4000029,CDM,460,RC,94729,HCPCS,OUTPATIENT,,,360,216,26,306,85,,244.8,Percent of total billed charges,85% of total billed charges,211.18,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,211.18,136.6,,71.6,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,9.56,fee schedule,35.15% of LA custom fee schedule,115.02,31.95,,101.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,24.32,case rate,pays based on per visit rate,115.02,31.95,,8.688,Fee Schedule,31.95% of LA custom fee schedule,1371.94,3023,
PULMONARY FUNCTION TEST MIP,4000098,CDM,460,RC,94799,HCPCS,OUTPATIENT,,,250,150,TC,212.5,85,,170,Percent of total billed charges,85% of total billed charges,131.78,136.6,,71.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,131.78,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,4.344,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,4.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,22.8,case rate,pays based on per visit rate,79.88,31.95,,5.44,Fee Schedule,31.95% of LA custom fee schedule,1372.94,3024,
PULMONARY FUNCTION TEST MEP,4000099,CDM,460,RC,94799,HCPCS,OUTPATIENT,,,250,150,TC,212.5,85,,170,Percent of total billed charges,85% of total billed charges,131.78,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,131.78,136.6,,258,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,14.824,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,14.824,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,8.816,case rate,pays based on per visit rate,79.88,31.95,,18.56,Fee Schedule,31.95% of LA custom fee schedule,1373.94,3025,
BASIC METABOLIC PANEL,4020001,CDM,301,RC,80048,HCPCS,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,39.48,136.6,,258,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.48,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,9.31,110,,10.888,fee schedule,110% of LA custom fee schedule,8.46,100,,10.888,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.24,38,,8.816,percent of total billed charges,38% of total billed charges,8.46,100,,13.632,Fee Schedule,100% of LA custom fee schedule,1374.94,3026,
ELECTROLYTE PANEL,4020002,CDM,301,RC,80051,HCPCS,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,32.16,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.16,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,7.71,110,,11.504,fee schedule,110% of LA custom fee schedule,7.01,100,,11.504,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.82,38,,10.944,percent of total billed charges,38% of total billed charges,7.01,100,,14.4,Fee Schedule,100% of LA custom fee schedule,1375.94,3027,
Electrolyte Panel Standard,4020002,CDM,301,RC,80051,HCPCS,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,32.16,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.16,136.6,,1398,fee schedule,136.60% of BCBS custom fee schedule,7.71,110,,10.888,fee schedule,110% of LA custom fee schedule,7.01,100,,10.888,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.82,38,,10.944,percent of total billed charges,38% of total billed charges,7.01,100,,13.632,Fee Schedule,100% of LA custom fee schedule,1376.94,3028,
COMP METABOLIC PANEL,4020003,CDM,301,RC,80053,HCPCS,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,49.29,136.6,,1398,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.29,136.6,,30.8,fee schedule,136.60% of BCBS custom fee schedule,11.62,110,,17.152,fee schedule,110% of LA custom fee schedule,10.56,100,,101.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.8,38,,21.888,percent of total billed charges,38% of total billed charges,10.56,100,,15.592,Fee Schedule,100% of LA custom fee schedule,1377.94,3029,
LIPID SURVEY,4020004,CDM,301,RC,80061,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.69,136.6,,30.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.69,136.6,,24.8,fee schedule,136.60% of BCBS custom fee schedule,14.73,110,,19.68,fee schedule,110% of LA custom fee schedule,13.39,100,,19.68,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,12.16,percent of total billed charges,38% of total billed charges,13.39,100,,24.64,Fee Schedule,100% of LA custom fee schedule,1378.94,3030,
RENAL FUNCTION PANEL,4020005,CDM,301,RC,80069,HCPCS,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,40.47,136.6,,24.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.47,136.6,,952,fee schedule,136.60% of BCBS custom fee schedule,9.55,110,,23.008,fee schedule,110% of LA custom fee schedule,8.68,100,,23.008,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.62,38,,12.16,percent of total billed charges,38% of total billed charges,8.68,100,,28.8,Fee Schedule,100% of LA custom fee schedule,1379.94,3031,
Hepatitis Panel (4) LC,4020007,CDM,301,RC,80074,HCPCS,OUTPATIENT,,,270,162,,229.5,85,,183.6,Percent of total billed charges,85% of total billed charges,222.04,136.6,,952,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,222.04,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,52.39,110,,29.136,fee schedule,110% of LA custom fee schedule,47.63,100,,29.136,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,102.6,38,,7.904,percent of total billed charges,38% of total billed charges,47.63,100,,36.48,Fee Schedule,100% of LA custom fee schedule,1380.94,3032,
Acute Hepatitis LC,4020007,CDM,300,RC,80074,HCPCS,OUTPATIENT,,,270,162,,229.5,85,,183.6,Percent of total billed charges,85% of total billed charges,222.04,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,222.04,136.6,,5.8,fee schedule,136.60% of BCBS custom fee schedule,52.39,110,,10.224,fee schedule,110% of LA custom fee schedule,47.63,100,,10.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,102.6,38,,34.352,percent of total billed charges,38% of total billed charges,47.63,100,,12.8,Fee Schedule,100% of LA custom fee schedule,1381.94,3033,
HEPATIC FUNCTION PANEL,4020008,CDM,301,RC,80076,HCPCS,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,38.1,136.6,,5.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,38.1,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,8.99,110,,8.944,fee schedule,110% of LA custom fee schedule,8.17,100,,8.944,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.48,38,,18.24,percent of total billed charges,38% of total billed charges,8.17,100,,11.2,Fee Schedule,100% of LA custom fee schedule,1382.94,3034,
DOT Drug Screen,4020009,CDM,301,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,2.4,percent of total billed charges,50% of total billed charges,19.17,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,10.64,percent of total billed charges,38% of total billed charges,24,40,,11.2,percent of total billed charges,40% of total billed charges,1383.94,3035,
"Carbamazepine(Tegretol), LC",4020015,CDM,301,RC,80156,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,54.24,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.24,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,15.6,110,,8.432,fee schedule,110% of LA custom fee schedule,14.18,100,,8.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,17.024,percent of total billed charges,38% of total billed charges,14.18,100,,10.56,Fee Schedule,100% of LA custom fee schedule,1384.94,3036,
"Cyclosporine, Blood LC",4020016,CDM,301,RC,80158,HCPCS,OUTPATIENT,,,102,61.2,,86.7,85,,69.36,Percent of total billed charges,85% of total billed charges,84.19,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.19,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,19.86,110,,8.944,fee schedule,110% of LA custom fee schedule,18.05,100,,8.944,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38.76,38,,17.024,percent of total billed charges,38% of total billed charges,18.05,100,,11.2,Fee Schedule,100% of LA custom fee schedule,1385.94,3037,
DIGOXIN,4020017,CDM,301,RC,80162,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,61.89,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.89,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,14.61,110,,8.432,fee schedule,110% of LA custom fee schedule,13.28,100,,8.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.5,38,,17.024,percent of total billed charges,38% of total billed charges,13.28,100,,10.56,Fee Schedule,100% of LA custom fee schedule,1386.94,3038,
"VALPROIC ACID,DEPAKENE",4020018,CDM,301,RC,80164,HCPCS,OUTPATIENT,,,76.76,46.056,,65.25,85,,52.2,Percent of total billed charges,85% of total billed charges,63.18,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.18,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,14.89,110,,8.944,fee schedule,110% of LA custom fee schedule,13.54,100,,8.944,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.17,38,,6.688,percent of total billed charges,38% of total billed charges,13.54,100,,11.2,Fee Schedule,100% of LA custom fee schedule,1387.94,3039,
"Gentamicin Peak, Serum LC",4020020,CDM,301,RC,80170,HCPCS,OUTPATIENT,,,65.96,39.576,,56.07,85,,44.856,Percent of total billed charges,85% of total billed charges,54.24,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.24,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,15.6,110,,8.432,fee schedule,110% of LA custom fee schedule,14.18,100,,8.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.06,38,,8.208,percent of total billed charges,38% of total billed charges,14.18,100,,10.56,Fee Schedule,100% of LA custom fee schedule,1388.94,3040,
"Gentamicin Trough, Serum LC",4020021,CDM,301,RC,80170,HCPCS,OUTPATIENT,,,65.96,39.576,,56.07,85,,44.856,Percent of total billed charges,85% of total billed charges,54.24,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.24,136.6,,97.6,fee schedule,136.60% of BCBS custom fee schedule,15.6,110,,8.432,fee schedule,110% of LA custom fee schedule,14.18,100,,8.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.06,38,,32.224,percent of total billed charges,38% of total billed charges,14.18,100,,10.56,Fee Schedule,100% of LA custom fee schedule,1389.94,3041,
"Lithium (Eskalith), Serum LC",4020024,CDM,301,RC,80178,HCPCS,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,30.83,136.6,,97.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.83,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,7.27,110,,10.992,fee schedule,110% of LA custom fee schedule,6.61,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.48,38,,20.064,percent of total billed charges,38% of total billed charges,6.61,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1390.94,3042,
PHENOBARB,4020025,CDM,301,RC,80184,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,53.42,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.42,136.6,,28.8,fee schedule,136.60% of BCBS custom fee schedule,16.19,110,,10.992,fee schedule,110% of LA custom fee schedule,14.72,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.7,38,,20.064,percent of total billed charges,38% of total billed charges,14.72,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1391.94,3043,
"PHENYTOIN;TOT,DILANTIN",4020026,CDM,301,RC,80185,HCPCS,OUTPATIENT,,,133,79.8,,113.05,85,,90.44,Percent of total billed charges,85% of total billed charges,61.8,136.6,,28.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.8,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,14.58,110,,10.992,fee schedule,110% of LA custom fee schedule,13.25,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,50.54,38,,45.6,percent of total billed charges,38% of total billed charges,13.25,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1392.94,3044,
"Phenytoin, Free, Serum LC",4020027,CDM,301,RC,80186,HCPCS,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,64.17,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,64.17,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,15.14,110,,11.248,fee schedule,110% of LA custom fee schedule,13.76,100,,11.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.64,38,,27.664,percent of total billed charges,38% of total billed charges,13.76,100,,14.08,Fee Schedule,100% of LA custom fee schedule,1393.94,3045,
Primidone Assay,4020028,CDM,301,RC,80188,HCPCS,OUTPATIENT,,,67,40.2,,56.95,85,,45.56,Percent of total billed charges,85% of total billed charges,77.34,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.34,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,18.25,110,,10.992,fee schedule,110% of LA custom fee schedule,16.59,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.46,38,,27.664,percent of total billed charges,38% of total billed charges,16.59,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1394.94,3046,
"Sirolimus (Rapamune), Blood LC",4020029,CDM,301,RC,80195,HCPCS,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,54,136.6,,10.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,15.1,110,,8.176,fee schedule,110% of LA custom fee schedule,13.73,100,,8.176,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.64,38,,12.768,percent of total billed charges,38% of total billed charges,13.73,100,,10.24,Fee Schedule,100% of LA custom fee schedule,1395.94,3047,
"Tacrolimus (FK506), Blood LC",4020030,CDM,301,RC,80197,HCPCS,OUTPATIENT,,,77.8,46.68,,66.13,85,,52.904,Percent of total billed charges,85% of total billed charges,63.96,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.96,136.6,,19.6,fee schedule,136.60% of BCBS custom fee schedule,15.1,110,,9.84,fee schedule,110% of LA custom fee schedule,13.73,100,,101.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.56,38,,35.872,percent of total billed charges,38% of total billed charges,13.73,100,,8.944,Fee Schedule,100% of LA custom fee schedule,1396.94,3048,
"Tacrolimus (FK506), Blood LC",4020030,CDM,301,RC,80197,HCPCS,OUTPATIENT,,,77.8,46.68,,66.13,85,,52.904,Percent of total billed charges,85% of total billed charges,63.96,136.6,,19.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.96,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,15.1,110,,9.28,fee schedule,110% of LA custom fee schedule,13.73,100,,101.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.56,38,,25.84,percent of total billed charges,38% of total billed charges,13.73,100,,8.432,Fee Schedule,100% of LA custom fee schedule,1397.94,3049,
"Tacrolimus (FK506), Blood LC",4020030,CDM,301,RC,80197,HCPCS,OUTPATIENT,,,77.8,46.68,,66.13,85,,52.904,Percent of total billed charges,85% of total billed charges,63.96,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.96,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,15.1,110,,2.56,fee schedule,110% of LA custom fee schedule,13.73,100,,2.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.56,38,,25.84,percent of total billed charges,38% of total billed charges,13.73,100,,3.2,Fee Schedule,100% of LA custom fee schedule,1398.94,3050,
THEOPHYLLINE,4020031,CDM,301,RC,80198,HCPCS,OUTPATIENT,,,142,85.2,,120.7,85,,96.56,Percent of total billed charges,85% of total billed charges,65.96,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,65.96,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,15.55,110,,2.56,fee schedule,110% of LA custom fee schedule,14.14,100,,2.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,53.96,38,,13.072,percent of total billed charges,38% of total billed charges,14.14,100,,3.2,Fee Schedule,100% of LA custom fee schedule,1399.94,3051,
"Theophylline, Serum LC",4020031,CDM,301,RC,80198,HCPCS,OUTPATIENT,,,142,85.2,,120.7,85,,96.56,Percent of total billed charges,85% of total billed charges,65.96,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,65.96,136.6,,100,fee schedule,136.60% of BCBS custom fee schedule,15.55,110,,6.136,fee schedule,110% of LA custom fee schedule,14.14,100,,6.136,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,53.96,38,,3.952,percent of total billed charges,38% of total billed charges,14.14,100,,7.68,Fee Schedule,100% of LA custom fee schedule,1400.94,3052,
"Topiramate (Topamax), Serum LC",4020033,CDM,301,RC,80201,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.6,136.6,,100,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.6,136.6,,155.2,fee schedule,136.60% of BCBS custom fee schedule,13.11,110,,6.136,fee schedule,110% of LA custom fee schedule,11.92,100,,6.136,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,3.952,percent of total billed charges,38% of total billed charges,11.92,100,,7.68,Fee Schedule,100% of LA custom fee schedule,1401.94,3053,
VANCOMYCIN PEAK,4020034,CDM,309,RC,80202,HCPCS,OUTPATIENT,,,154,92.4,,130.9,85,,104.72,Percent of total billed charges,85% of total billed charges,63.18,136.6,,155.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.18,136.6,,276,fee schedule,136.60% of BCBS custom fee schedule,14.89,110,,6.904,fee schedule,110% of LA custom fee schedule,13.54,100,,6.904,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,58.52,38,,3.952,percent of total billed charges,38% of total billed charges,13.54,100,,8.64,Fee Schedule,100% of LA custom fee schedule,1402.94,3054,
"VANCOMYCIN TROUGH, SERUM",4020035,CDM,301,RC,80202,HCPCS,OUTPATIENT,,,77,46.2,,65.45,85,,52.36,Percent of total billed charges,85% of total billed charges,63.18,136.6,,276,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.18,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,14.89,110,,7.16,fee schedule,110% of LA custom fee schedule,13.54,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.26,38,,4.56,percent of total billed charges,38% of total billed charges,13.54,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1403.94,3055,
Cortisol (Dexamethasone Suppression Test) With reflex to Dex,4020036,CDM,301,RC,80299,HCPCS,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,63.85,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.85,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,19.38,110,,6.904,fee schedule,110% of LA custom fee schedule,17.62,100,,6.904,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.34,38,,3.952,percent of total billed charges,38% of total billed charges,17.62,100,,8.64,Fee Schedule,100% of LA custom fee schedule,1404.94,3056,
"Cannabinoid Confirmation, Ur LC",4020037,CDM,301,RC,80349,HCPCS,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,26.01,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.01,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,62.3,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,62.3,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,74.1,38,,13.376,percent of total billed charges,38% of total billed charges,78,40,,9.28,percent of total billed charges,40% of total billed charges,1405.94,3057,
URINE DRUG SCREEN,4020038,CDM,301,RC,80305,HCPCS,OUTPATIENT,,,146,87.6,,124.1,85,,99.28,Percent of total billed charges,85% of total billed charges,41.85,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,41.85,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,13.86,110,,7.416,fee schedule,110% of LA custom fee schedule,12.6,100,,7.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,55.48,38,,13.376,percent of total billed charges,38% of total billed charges,12.6,100,,9.28,Fee Schedule,100% of LA custom fee schedule,1406.94,3058,
Urine Drug Screen FMC,4020038,CDM,301,RC,80305,HCPCS,OUTPATIENT,,,146,87.6,,124.1,85,,99.28,Percent of total billed charges,85% of total billed charges,41.85,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,41.85,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,13.86,110,,7.16,fee schedule,110% of LA custom fee schedule,12.6,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,55.48,38,,15.504,percent of total billed charges,38% of total billed charges,12.6,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1407.94,3059,
Nicotine Screen,4020038,CDM,300,RC,80305,HCPCS,OUTPATIENT,,,146,87.6,,124.1,85,,99.28,Percent of total billed charges,85% of total billed charges,41.85,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,41.85,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,13.86,110,,7.16,fee schedule,110% of LA custom fee schedule,12.6,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,55.48,38,,15.504,percent of total billed charges,38% of total billed charges,12.6,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1408.94,3060,
"Cocaine Metabolite Confirm,Ur LC",4020039,CDM,301,RC,80353,HCPCS,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,21.21,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.21,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,62.3,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,62.3,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,74.1,38,,11.552,percent of total billed charges,38% of total billed charges,78,40,,1.28,percent of total billed charges,40% of total billed charges,1409.94,3061,
ETHANOL BLOOD (ETOH)  80320,4020040,CDM,301,RC,82077,HCPCS,OUTPATIENT,,,229,137.4,,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,48.64,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,48.64,136.6,,88.8,fee schedule,136.60% of BCBS custom fee schedule,14.25,110,,24.024,fee schedule,110% of LA custom fee schedule,12.95,100,,24.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,87.02,38,,6.896,percent of total billed charges,38% of total billed charges,12.95,100,,30.08,Fee Schedule,100% of LA custom fee schedule,1410.94,3062,
ASA LEVEL,4020041,CDM,301,RC,80143,HCPCS,OUTPATIENT,,,229,137.4,,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,52.5,136.6,,88.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.5,136.6,,140.4,fee schedule,136.60% of BCBS custom fee schedule,15.38,110,,14.056,fee schedule,110% of LA custom fee schedule,13.98,100,,14.056,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,87.02,38,,6.896,percent of total billed charges,38% of total billed charges,13.98,100,,17.6,Fee Schedule,100% of LA custom fee schedule,1411.94,3063,
Salicylate Level,4020042,CDM,301,RC,80179,HCPCS,OUTPATIENT,,,229,137.4,,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,52.5,136.6,,140.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.5,136.6,,138.8,fee schedule,136.60% of BCBS custom fee schedule,15.38,110,,30.672,fee schedule,110% of LA custom fee schedule,13.98,100,,30.672,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,87.02,38,,4.256,percent of total billed charges,38% of total billed charges,13.98,100,,38.4,Fee Schedule,100% of LA custom fee schedule,1412.94,3064,
Clonazepam (Klonopin) LC,4020043,CDM,301,RC,80346,HCPCS,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,25.84,136.6,,138.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.84,136.6,,1800,fee schedule,136.60% of BCBS custom fee schedule,29.71,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,29.71,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.34,38,,10.64,percent of total billed charges,38% of total billed charges,37.2,40,,8.32,percent of total billed charges,40% of total billed charges,1413.94,3065,
Drug Test Def 1-7 Classes,4020044,CDM,301,RC,G0480,HCPCS,OUTPATIENT,,,229,137.4,,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,225.14,136.6,,1800,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,225.14,136.6,,1800,fee schedule,136.60% of BCBS custom fee schedule,97.43,110,,2.048,fee schedule,110% of LA custom fee schedule,88.57,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,87.02,38,,47.424,percent of total billed charges,38% of total billed charges,88.57,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1414.94,3066,
Drug Test Def 8-14 Classes,4020045,CDM,301,RC,G0481,HCPCS,OUTPATIENT,,,313,187.8,,266.05,85,,212.84,Percent of total billed charges,85% of total billed charges,346.38,136.6,,1800,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,346.38,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,133.32,110,,1.968,fee schedule,110% of LA custom fee schedule,121.2,100,,1.968,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,118.94,38,,20.672,percent of total billed charges,38% of total billed charges,121.2,100,,2.464,Fee Schedule,100% of LA custom fee schedule,1415.94,3067,
Drug Test Def 15-21 Classes,4020046,CDM,301,RC,G0482,HCPCS,OUTPATIENT,,,397,238.2,,337.45,85,,269.96,Percent of total billed charges,85% of total billed charges,467.6,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,467.6,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,126.84,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,126.84,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,24.32,percent of total billed charges,38% of total billed charges,158.8,40,,86.4,percent of total billed charges,40% of total billed charges,1416.94,3068,
Drug Test Def 22+ Classes,4020047,CDM,301,RC,G0483,HCPCS,OUTPATIENT,,,494,296.4,,419.9,85,,335.92,Percent of total billed charges,85% of total billed charges,606.15,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,606.15,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,157.83,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,157.83,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,187.72,38,,14.592,percent of total billed charges,38% of total billed charges,197.6,40,,2.24,percent of total billed charges,40% of total billed charges,1417.94,3069,
Urinalysis Complete 7,4020048,CDM,307,RC,81001,HCPCS,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,14.78,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.78,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,3.49,110,,4.088,fee schedule,110% of LA custom fee schedule,3.17,100,,4.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.84,38,,44.688,percent of total billed charges,38% of total billed charges,3.17,100,,5.12,Fee Schedule,100% of LA custom fee schedule,1418.94,3070,
Urinalysis Complete 7,4020048,CDM,307,RC,81001,HCPCS,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,14.78,136.6,,0.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.78,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,3.49,110,,3.832,fee schedule,110% of LA custom fee schedule,3.17,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.84,38,,6.688,percent of total billed charges,38% of total billed charges,3.17,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1419.94,3071,
Urinalysis w/ Culture if Ind,4020048,CDM,307,RC,81001,HCPCS,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,14.78,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.78,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,3.49,110,,4.088,fee schedule,110% of LA custom fee schedule,3.17,100,,4.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.84,38,,6.688,percent of total billed charges,38% of total billed charges,3.17,100,,5.12,Fee Schedule,100% of LA custom fee schedule,1420.94,3072,
Urine Dipstick POC,4020049,CDM,300,RC,81003,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,10.48,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.48,136.6,,124.8,fee schedule,136.60% of BCBS custom fee schedule,2.48,110,,4.088,fee schedule,110% of LA custom fee schedule,2.25,100,,4.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,6.688,percent of total billed charges,38% of total billed charges,2.25,100,,5.12,Fee Schedule,100% of LA custom fee schedule,1421.94,3073,
Urinalysis Standard,4020050,CDM,307,RC,81003,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,10.48,136.6,,124.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.48,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,2.48,110,,3.832,fee schedule,110% of LA custom fee schedule,2.25,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,6.08,percent of total billed charges,38% of total billed charges,2.25,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1422.94,3074,
Urinalysis Dipstick Standard,4020050,CDM,307,RC,81003,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,10.48,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.48,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,2.48,110,,18.912,fee schedule,110% of LA custom fee schedule,2.25,100,,18.912,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,10.336,percent of total billed charges,38% of total billed charges,2.25,100,,23.68,Fee Schedule,100% of LA custom fee schedule,1423.94,3075,
Urine Pregnancy Test POC,4020051,CDM,300,RC,81025,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,29.51,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.51,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,8.97,110,,16.064,fee schedule,110% of LA custom fee schedule,8.15,100,,16.064,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.5,38,,10.336,percent of total billed charges,38% of total billed charges,8.15,100,,20.112,Fee Schedule,100% of LA custom fee schedule,1424.94,3076,
UA PREGNANCY TEST,4020051,CDM,307,RC,81025,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,29.51,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.51,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,8.97,110,,10.224,fee schedule,110% of LA custom fee schedule,8.15,100,,10.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,8.15,100,,12.8,Fee Schedule,100% of LA custom fee schedule,1425.94,3077,
"Fragile X, PCR and Southern Blot Analysis",4020052,CDM,301,RC,81243,HCPCS,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,160.64,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,160.64,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,54.32,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.6,38,,10.944,percent of total billed charges,38% of total billed charges,68,40,,12.8,percent of total billed charges,40% of total billed charges,1426.94,3078,
"81244 Fragile X, PCR and Southern Blot Analysis",4020052,CDM,301,RC,81243,HCPCS,OUTPATIENT,,,135,81,,114.75,85,,91.8,Percent of total billed charges,85% of total billed charges,160.64,136.6,,4.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,160.64,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,43.13,31.95,,10.08,percent of total billed charges,31.95% of total billed charges,43.13,31.95,,10.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,51.3,38,,10.944,percent of total billed charges,38% of total billed charges,54,40,,12.624,percent of total billed charges,40% of total billed charges,1427.94,3079,
HLA B 27 Disease Association LC,4020054,CDM,310,RC,81374,HCPCS,OUTPATIENT,,,495,297,,420.75,85,,336.6,Percent of total billed charges,85% of total billed charges,252.94,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,252.94,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,158.15,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,158.15,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,188.1,38,,10.944,percent of total billed charges,38% of total billed charges,198,40,,10.56,percent of total billed charges,40% of total billed charges,1428.94,3080,
Beta-Hydroxybutyrate LC,4020055,CDM,301,RC,82010,HCPCS,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,38.1,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,38.1,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,8.99,110,,5.624,fee schedule,110% of LA custom fee schedule,8.17,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.54,38,,10.944,percent of total billed charges,38% of total billed charges,8.17,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1429.94,3081,
Ketone Serum,4020056,CDM,301,RC,82009,HCPCS,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,21.06,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.06,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,4.97,110,,5.624,fee schedule,110% of LA custom fee schedule,4.52,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.88,38,,10.944,percent of total billed charges,38% of total billed charges,4.52,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1430.94,3082,
ACETONE-SERUM,4020056,CDM,301,RC,82009,HCPCS,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,21.06,136.6,,1.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.06,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,4.97,110,,5.368,fee schedule,110% of LA custom fee schedule,4.52,100,,5.368,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.88,38,,10.944,percent of total billed charges,38% of total billed charges,4.52,100,,6.72,Fee Schedule,100% of LA custom fee schedule,1431.94,3083,
"ACTH, Plasma LC",4020057,CDM,301,RC,82024,HCPCS,OUTPATIENT,,,218.84,131.304,,186.01,85,,148.808,Percent of total billed charges,85% of total billed charges,180.11,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,180.11,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,42.48,110,,5.624,fee schedule,110% of LA custom fee schedule,38.62,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,83.16,38,,10.944,percent of total billed charges,38% of total billed charges,38.62,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1432.94,3084,
ALBUMIN SERUM,4020058,CDM,301,RC,82040,HCPCS,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,23.09,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,23.09,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,5.45,110,,5.368,fee schedule,110% of LA custom fee schedule,4.95,100,,5.368,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.64,38,,10.944,percent of total billed charges,38% of total billed charges,4.95,100,,6.72,Fee Schedule,100% of LA custom fee schedule,1433.94,3085,
"Microalb/Creat Ratio, Randm Ur LC",4020059,CDM,300,RC,82043,HCPCS,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,27.01,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.01,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,6.36,110,,5.624,fee schedule,110% of LA custom fee schedule,5.78,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.54,38,,10.944,percent of total billed charges,38% of total billed charges,5.78,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1434.94,3086,
"Microalbumin, Random Urine LC",4020059,CDM,301,RC,82043,HCPCS,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,27.01,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.01,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,6.36,110,,5.624,fee schedule,110% of LA custom fee schedule,5.78,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.54,38,,10.944,percent of total billed charges,38% of total billed charges,5.78,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1435.94,3087,
Aldolase LC,4020061,CDM,301,RC,82085,HCPCS,OUTPATIENT,,,67,40.2,,56.95,85,,45.56,Percent of total billed charges,85% of total billed charges,45.26,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.26,136.6,,24.4,fee schedule,136.60% of BCBS custom fee schedule,10.68,110,,5.624,fee schedule,110% of LA custom fee schedule,9.71,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.46,38,,38,percent of total billed charges,38% of total billed charges,9.71,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1436.94,3088,
"Aldosterone LCMS, Serum LC",4020062,CDM,301,RC,82088,HCPCS,OUTPATIENT,,,230.88,138.528,,196.25,85,,157,Percent of total billed charges,85% of total billed charges,190,136.6,,24.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,190,136.6,,26.8,fee schedule,136.60% of BCBS custom fee schedule,44.83,110,,5.624,fee schedule,110% of LA custom fee schedule,40.75,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,87.73,38,,37.088,percent of total billed charges,38% of total billed charges,40.75,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1437.94,3089,
Aldosterone/Renin Ratio LC,4020062,CDM,301,RC,84244,HCPCS,OUTPATIENT,,,124.6,74.76,,105.91,85,,84.728,Percent of total billed charges,85% of total billed charges,102.55,136.6,,26.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,102.55,136.6,,9.6,fee schedule,136.60% of BCBS custom fee schedule,24.19,110,,6.952,fee schedule,110% of LA custom fee schedule,21.99,100,,6.952,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,47.35,38,,37.088,percent of total billed charges,38% of total billed charges,21.99,100,,8.704,Fee Schedule,100% of LA custom fee schedule,1438.94,3090,
"Aldosterone, Urine LC",4020062,CDM,301,RC,82088,HCPCS,OUTPATIENT,,,230.88,138.528,,196.25,85,,157,Percent of total billed charges,85% of total billed charges,190,136.6,,9.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,190,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,44.83,110,,6.544,fee schedule,110% of LA custom fee schedule,40.75,100,,6.544,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,87.73,38,,28.576,percent of total billed charges,38% of total billed charges,40.75,100,,8.192,Fee Schedule,100% of LA custom fee schedule,1439.94,3091,
"Alpha-1-Antitrypsin, Serum LC",4020063,CDM,309,RC,82103,HCPCS,OUTPATIENT,,,92,55.2,,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,62.63,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,62.63,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,14.78,110,,8.944,fee schedule,110% of LA custom fee schedule,13.44,100,,8.944,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.96,38,,12.464,percent of total billed charges,38% of total billed charges,13.44,100,,11.2,Fee Schedule,100% of LA custom fee schedule,1440.94,3092,
"AFP, Serum, Tumor Marker LC",4020065,CDM,301,RC,82105,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,78.22,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.22,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,18.36,110,,6.952,fee schedule,110% of LA custom fee schedule,16.69,100,,6.952,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.1,38,,8.816,percent of total billed charges,38% of total billed charges,16.69,100,,8.704,Fee Schedule,100% of LA custom fee schedule,1441.94,3093,
AMMONIA,4020066,CDM,301,RC,82140,HCPCS,OUTPATIENT,,,83,49.8,,70.55,85,,56.44,Percent of total billed charges,85% of total billed charges,67.94,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,67.94,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,16.03,110,,6.952,fee schedule,110% of LA custom fee schedule,14.57,100,,6.952,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.54,38,,22.192,percent of total billed charges,38% of total billed charges,14.57,100,,8.704,Fee Schedule,100% of LA custom fee schedule,1442.94,3094,
Ammonia Level,4020066,CDM,301,RC,82140,HCPCS,OUTPATIENT,,,83,49.8,,70.55,85,,56.44,Percent of total billed charges,85% of total billed charges,67.94,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,67.94,136.6,,20.4,fee schedule,136.60% of BCBS custom fee schedule,16.03,110,,6.952,fee schedule,110% of LA custom fee schedule,14.57,100,,6.952,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.54,38,,20.672,percent of total billed charges,38% of total billed charges,14.57,100,,8.704,Fee Schedule,100% of LA custom fee schedule,1443.94,3095,
AMYLASE,4020068,CDM,301,RC,82150,HCPCS,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,30.24,136.6,,20.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.24,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,7.13,110,,17.896,fee schedule,110% of LA custom fee schedule,6.48,100,,17.896,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.06,38,,20.672,percent of total billed charges,38% of total billed charges,6.48,100,,22.4,Fee Schedule,100% of LA custom fee schedule,1444.94,3096,
Androstenedione LC,4020069,CDM,301,RC,82157,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,136.49,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,136.49,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,32.21,110,,9.456,fee schedule,110% of LA custom fee schedule,29.28,100,,9.456,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,76,38,,20.672,percent of total billed charges,38% of total billed charges,29.28,100,,11.84,Fee Schedule,100% of LA custom fee schedule,1445.94,3097,
Angiotensin-Converting Enzyme LC,4020070,CDM,301,RC,82164,HCPCS,OUTPATIENT,,,82.72,49.632,,70.31,85,,56.248,Percent of total billed charges,85% of total billed charges,68.04,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,68.04,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,16.06,110,,10.968,fee schedule,110% of LA custom fee schedule,14.6,100,,10.968,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.43,38,,32.832,percent of total billed charges,38% of total billed charges,14.6,100,,13.728,Fee Schedule,100% of LA custom fee schedule,1446.94,3098,
Assay of Apolipoprotein,4020072,CDM,301,RC,82172,HCPCS,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,72.25,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,72.25,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,20.13,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,20.13,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,27.056,percent of total billed charges,38% of total billed charges,25.2,40,,13.728,percent of total billed charges,40% of total billed charges,1447.94,3099,
Vitamin C LC,4020073,CDM,309,RC,82180,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,39.48,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.48,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,10.88,110,,9.584,fee schedule,110% of LA custom fee schedule,9.89,100,,9.584,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,28.576,percent of total billed charges,38% of total billed charges,9.89,100,,12,Fee Schedule,100% of LA custom fee schedule,1448.94,3100,
BILIRUBIN TOTAL,4020075,CDM,309,RC,82247,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,16.24,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.24,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,5.32,110,,12.96,fee schedule,110% of LA custom fee schedule,4.84,100,,12.96,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,20.064,percent of total billed charges,38% of total billed charges,4.84,100,,16.224,Fee Schedule,100% of LA custom fee schedule,1449.94,3101,
Bilirubin; total,4020075,CDM,309,RC,82247,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,16.24,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.24,136.6,,0.792,fee schedule,136.60% of BCBS custom fee schedule,5.32,110,,2.808,fee schedule,110% of LA custom fee schedule,4.84,100,,2.808,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,40.128,percent of total billed charges,38% of total billed charges,4.84,100,,3.52,Fee Schedule,100% of LA custom fee schedule,1450.94,3102,
BILIRUBIN; DIRECT,4020076,CDM,301,RC,82248,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,16.24,136.6,,0.792,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.24,136.6,,0.8,fee schedule,136.60% of BCBS custom fee schedule,5.32,110,,1.792,fee schedule,110% of LA custom fee schedule,4.84,100,,1.792,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.6,38,,37.088,percent of total billed charges,38% of total billed charges,4.84,100,,2.24,Fee Schedule,100% of LA custom fee schedule,1451.94,3103,
Bilirubin Total and Direct,4020077,CDM,301,RC,1-82247|2-,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,34,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34,50,,5,percent of total billed charges,50% of total billed charges,21.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,21.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.84,38,,35.872,percent of total billed charges,38% of total billed charges,27.2,40,,3.84,percent of total billed charges,40% of total billed charges,1452.94,3104,
Stool for Occult Blood,4020078,CDM,300,RC,82270,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,15.15,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,15.15,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,3.55,110,,8.688,fee schedule,110% of LA custom fee schedule,3.23,100,,8.688,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,35.872,percent of total billed charges,38% of total billed charges,3.23,100,,10.88,Fee Schedule,100% of LA custom fee schedule,1453.94,3105,
Occult Blood Stool lll,4020078,CDM,301,RC,82270,HCPCS,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,15.15,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,15.15,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,3.55,110,,7.16,fee schedule,110% of LA custom fee schedule,3.23,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.84,38,,35.872,percent of total billed charges,38% of total billed charges,3.23,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1454.94,3106,
"Occult Blood, Gastric Fluid LC",4020079,CDM,301,RC,82271,HCPCS,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,12.79,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,12.79,136.6,,180,fee schedule,136.60% of BCBS custom fee schedule,4.96,110,,0.56,fee schedule,110% of LA custom fee schedule,4.51,100,,101.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.84,38,,8.816,percent of total billed charges,38% of total billed charges,4.51,100,,0.512,Fee Schedule,100% of LA custom fee schedule,1455.94,3107,
Vitamin D 25 Hydroxy Level,4020083,CDM,301,RC,82306,HCPCS,OUTPATIENT,,,167.76,100.656,,142.6,85,,114.08,Percent of total billed charges,85% of total billed charges,138.02,136.6,,180,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,138.02,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,32.56,110,,2.304,fee schedule,110% of LA custom fee schedule,29.6,100,,2.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,63.75,38,,15.2,percent of total billed charges,38% of total billed charges,29.6,100,,2.88,Fee Schedule,100% of LA custom fee schedule,1456.94,3108,
"Vitamin D, 25-Hydroxy LC",4020083,CDM,301,RC,82306,HCPCS,OUTPATIENT,,,167.76,100.656,,142.6,85,,114.08,Percent of total billed charges,85% of total billed charges,138.02,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,138.02,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,32.56,110,,9.224,fee schedule,110% of LA custom fee schedule,29.6,100,,9.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,63.75,38,,361.592,percent of total billed charges,38% of total billed charges,29.6,100,,11.544,Fee Schedule,100% of LA custom fee schedule,1457.94,3109,
"Calcitonin, Serum LC",4020084,CDM,301,RC,82308,HCPCS,OUTPATIENT,,,130,78,,110.5,85,,88.4,Percent of total billed charges,85% of total billed charges,124.83,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,124.83,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,29.47,110,,17.712,fee schedule,110% of LA custom fee schedule,26.79,100,,101.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,49.4,38,,19.76,percent of total billed charges,38% of total billed charges,26.79,100,,16.104,Fee Schedule,100% of LA custom fee schedule,1458.94,3110,
CALCIUM; SERUM,4020085,CDM,301,RC,82310,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,24.03,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.03,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,5.68,110,,4.856,fee schedule,110% of LA custom fee schedule,5.16,100,,4.856,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,41.952,percent of total billed charges,38% of total billed charges,5.16,100,,6.08,Fee Schedule,100% of LA custom fee schedule,1459.94,3111,
"Calcium, Ionized, Serum LC",4020086,CDM,301,RC,82330,HCPCS,OUTPATIENT,,,77,46.2,,65.45,85,,52.36,Percent of total billed charges,85% of total billed charges,63.71,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.71,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,15.05,110,,11.504,fee schedule,110% of LA custom fee schedule,13.68,100,,11.504,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.26,38,,24.928,percent of total billed charges,38% of total billed charges,13.68,100,,14.4,Fee Schedule,100% of LA custom fee schedule,1460.94,3112,
"Calcium, 24Hr Urine LC",4020087,CDM,300,RC,82340,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,28.13,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.13,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,6.63,110,,1.28,fee schedule,110% of LA custom fee schedule,6.03,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,9.728,percent of total billed charges,38% of total billed charges,6.03,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1461.94,3113,
Calcium/Creatinine Ratio LC,4020087,CDM,300,RC,82340,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,28.13,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.13,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,6.63,110,,5.624,fee schedule,110% of LA custom fee schedule,6.03,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,128.592,percent of total billed charges,38% of total billed charges,6.03,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1462.94,3114,
CARBON DIOXIDE,4020089,CDM,301,RC,82374,HCPCS,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,22.8,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.8,136.6,,325.2,fee schedule,136.60% of BCBS custom fee schedule,5.37,110,,7.672,fee schedule,110% of LA custom fee schedule,4.88,100,,7.672,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.64,38,,128.592,percent of total billed charges,38% of total billed charges,4.88,100,,9.6,Fee Schedule,100% of LA custom fee schedule,1463.94,3115,
CEA LC,4020090,CDM,301,RC,82378,HCPCS,OUTPATIENT,,,107,64.2,,90.95,85,,72.76,Percent of total billed charges,85% of total billed charges,88.45,136.6,,325.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,88.45,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,20.86,110,,20.192,fee schedule,110% of LA custom fee schedule,18.96,100,,20.192,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,40.66,38,,6.08,percent of total billed charges,38% of total billed charges,18.96,100,,25.28,Fee Schedule,100% of LA custom fee schedule,1464.94,3116,
"Catecholamines, Plasma LC",4020092,CDM,302,RC,82384,HCPCS,OUTPATIENT,,,143,85.8,,121.55,85,,97.24,Percent of total billed charges,85% of total billed charges,117.72,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,117.72,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,27.78,110,,9.712,fee schedule,110% of LA custom fee schedule,25.25,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,54.34,38,,7.296,percent of total billed charges,38% of total billed charges,25.25,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1465.94,3117,
"Catecholamines,Ur.,Free,24 Hr LC",4020092,CDM,301,RC,82384,HCPCS,OUTPATIENT,,,143,85.8,,121.55,85,,97.24,Percent of total billed charges,85% of total billed charges,117.72,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,117.72,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,27.78,110,,2.12,fee schedule,110% of LA custom fee schedule,25.25,100,,2.12,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,54.34,38,,26.752,percent of total billed charges,38% of total billed charges,25.25,100,,2.656,Fee Schedule,100% of LA custom fee schedule,1466.94,3118,
PTHrP (PTH-Related Peptide) LC,4020093,CDM,301,RC,82397,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,21.68,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.68,136.6,,404,fee schedule,136.60% of BCBS custom fee schedule,6.25,110,,3.832,fee schedule,110% of LA custom fee schedule,5.68,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,29.328,percent of total billed charges,38% of total billed charges,5.68,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1467.94,3119,
Ceruloplasmin LC,4020094,CDM,309,RC,82390,HCPCS,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,50.06,136.6,,404,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.06,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,11.81,110,,2.808,fee schedule,110% of LA custom fee schedule,10.74,100,,2.808,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.12,38,,29.328,percent of total billed charges,38% of total billed charges,10.74,100,,3.52,Fee Schedule,100% of LA custom fee schedule,1468.94,3120,
CHLORIDE;BLD,4020095,CDM,301,RC,82435,HCPCS,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,21.41,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.41,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,5.06,110,,10.992,fee schedule,110% of LA custom fee schedule,4.6,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.88,38,,29.328,percent of total billed charges,38% of total billed charges,4.6,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1469.94,3121,
"Chloride, Urine LC",4020096,CDM,301,RC,82436,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,23.43,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,23.43,136.6,,758,fee schedule,136.60% of BCBS custom fee schedule,6.33,110,,3.832,fee schedule,110% of LA custom fee schedule,5.75,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,24.016,percent of total billed charges,38% of total billed charges,5.75,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1470.94,3122,
CHOL SERUM/WHOLE BLD T,4020098,CDM,301,RC,82465,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,20.3,136.6,,758,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.3,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,4.69,110,,0.56,fee schedule,110% of LA custom fee schedule,4.26,100,,101.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.5,38,,30.096,percent of total billed charges,38% of total billed charges,4.26,100,,0.512,Fee Schedule,100% of LA custom fee schedule,1471.94,3123,
"Cholesterol, serum or whole blood, total",4020098,CDM,301,RC,82465,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,20.3,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.3,136.6,,138,fee schedule,136.60% of BCBS custom fee schedule,4.69,110,,1.024,fee schedule,110% of LA custom fee schedule,4.26,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.5,38,,79.648,percent of total billed charges,38% of total billed charges,4.26,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1472.94,3124,
"Lamotrigine (Lamictal), Serum LC",4020100,CDM,301,RC,80175,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,50.94,136.6,,138,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.94,136.6,,104,fee schedule,136.60% of BCBS custom fee schedule,14.58,110,,21.728,fee schedule,110% of LA custom fee schedule,13.25,100,,21.728,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.8,38,,37.088,percent of total billed charges,38% of total billed charges,13.25,100,,27.2,Fee Schedule,100% of LA custom fee schedule,1473.94,3125,
"C-Telopeptide, Serum LC",4020101,CDM,301,RC,82523,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,87.12,136.6,,104,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,87.12,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,20.55,110,,6.648,fee schedule,110% of LA custom fee schedule,18.68,100,,6.648,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.5,38,,20.064,percent of total billed charges,38% of total billed charges,18.68,100,,8.32,Fee Schedule,100% of LA custom fee schedule,1474.94,3126,
"N-Telopeptide, Serum LC",4020101,CDM,301,RC,82523,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,87.12,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,87.12,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,20.55,110,,9.968,fee schedule,110% of LA custom fee schedule,18.68,100,,9.968,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.5,38,,20.064,percent of total billed charges,38% of total billed charges,18.68,100,,12.48,Fee Schedule,100% of LA custom fee schedule,1475.94,3127,
Copper Serum LC,4020102,CDM,301,RC,82525,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,57.86,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.86,136.6,,408,fee schedule,136.60% of BCBS custom fee schedule,13.65,110,,23.768,fee schedule,110% of LA custom fee schedule,12.41,100,,23.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.3,38,,20.064,percent of total billed charges,38% of total billed charges,12.41,100,,29.76,Fee Schedule,100% of LA custom fee schedule,1476.94,3128,
"Cortisol, Urinary Free LC",4020103,CDM,301,RC,82530,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,77.92,136.6,,408,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.92,136.6,,86.8,fee schedule,136.60% of BCBS custom fee schedule,18.38,110,,2.248,fee schedule,110% of LA custom fee schedule,16.71,100,,101.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.1,38,,20.064,percent of total billed charges,38% of total billed charges,16.71,100,,2.048,Fee Schedule,100% of LA custom fee schedule,1477.94,3129,
Cortisol AM LC,4020104,CDM,301,RC,82533,HCPCS,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,76,136.6,,86.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76,136.6,,438.4,fee schedule,136.60% of BCBS custom fee schedule,17.93,110,,2.048,fee schedule,110% of LA custom fee schedule,16.3,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.56,38,,20.064,percent of total billed charges,38% of total billed charges,16.3,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1478.94,3130,
Cortisol LC,4020104,CDM,301,RC,82533,HCPCS,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,76,136.6,,438.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76,136.6,,438.4,fee schedule,136.60% of BCBS custom fee schedule,17.93,110,,2.248,fee schedule,110% of LA custom fee schedule,16.3,100,,101.728,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.56,38,,20.064,percent of total billed charges,38% of total billed charges,16.3,100,,2.048,Fee Schedule,100% of LA custom fee schedule,1479.94,3131,
Cortisol - PM LC,4020104,CDM,301,RC,82533,HCPCS,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,76,136.6,,438.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76,136.6,,1.48,fee schedule,136.60% of BCBS custom fee schedule,17.93,110,,2.048,fee schedule,110% of LA custom fee schedule,16.3,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.56,38,,24.624,percent of total billed charges,38% of total billed charges,16.3,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1480.94,3132,
Salivary Cortisol LC,4020105,CDM,301,RC,82533,HCPCS,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,76,136.6,,1.48,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76,136.6,,1.744,fee schedule,136.60% of BCBS custom fee schedule,17.93,110,,9.712,fee schedule,110% of LA custom fee schedule,16.3,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.56,38,,36.176,percent of total billed charges,38% of total billed charges,16.3,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1481.94,3133,
"Levetiracetam (Keppra), S LC",4020108,CDM,301,RC,80177,HCPCS,OUTPATIENT,,,102.28,61.368,,86.94,85,,69.552,Percent of total billed charges,85% of total billed charges,50.94,136.6,,1.744,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.94,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,14.58,110,,9.712,fee schedule,110% of LA custom fee schedule,13.25,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38.87,38,,24.624,percent of total billed charges,38% of total billed charges,13.25,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1482.94,3134,
"Oxcarbazepine (Trileptal), LC",4020109,CDM,301,RC,80183,HCPCS,OUTPATIENT,,,102,61.2,,86.7,85,,69.36,Percent of total billed charges,85% of total billed charges,50.94,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.94,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,14.58,110,,9.712,fee schedule,110% of LA custom fee schedule,13.25,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38.76,38,,36.176,percent of total billed charges,38% of total billed charges,13.25,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1483.94,3135,
"Zonisamide(Zonegran), Serum LC",4020110,CDM,301,RC,80203,HCPCS,OUTPATIENT,,,102.28,61.368,,86.94,85,,69.552,Percent of total billed charges,85% of total billed charges,50.94,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.94,136.6,,4.104,fee schedule,136.60% of BCBS custom fee schedule,14.58,110,,13.032,fee schedule,110% of LA custom fee schedule,13.25,100,,13.032,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38.87,38,,24.624,percent of total billed charges,38% of total billed charges,13.25,100,,16.32,Fee Schedule,100% of LA custom fee schedule,1484.94,3136,
CREATINE KINASE TOTAL,4020111,CDM,301,RC,82550,HCPCS,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,30.35,136.6,,4.104,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.35,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,7.16,110,,5.368,fee schedule,110% of LA custom fee schedule,6.51,100,,5.368,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.06,38,,36.176,percent of total billed charges,38% of total billed charges,6.51,100,,6.72,Fee Schedule,100% of LA custom fee schedule,1485.94,3137,
CREATINE KINASE MB FRACTION,4020112,CDM,301,RC,82553,HCPCS,OUTPATIENT,,,106,63.6,,90.1,85,,72.08,Percent of total billed charges,85% of total billed charges,53.83,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.83,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,12.71,110,,2.048,fee schedule,110% of LA custom fee schedule,11.55,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,40.28,38,,26.144,percent of total billed charges,38% of total billed charges,11.55,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1486.94,3138,
CREATININE; BLD,4020113,CDM,301,RC,82565,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,23.89,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,23.89,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,5.63,110,,34.584,fee schedule,110% of LA custom fee schedule,5.12,100,,1022.4,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,15.2,percent of total billed charges,38% of total billed charges,5.12,100,,31.44,Fee Schedule,100% of LA custom fee schedule,1487.94,3139,
"Creatinine, Urine LC",4020115,CDM,301,RC,82570,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,0.768,fee schedule,110% of LA custom fee schedule,5.18,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,29.488,percent of total billed charges,38% of total billed charges,5.18,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1488.94,3140,
Prot+CreatU (Random) LC,4020115,CDM,301,RC,82570,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,4.088,fee schedule,110% of LA custom fee schedule,5.18,100,,4.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,18.544,percent of total billed charges,38% of total billed charges,5.18,100,,5.12,Fee Schedule,100% of LA custom fee schedule,1489.94,3141,
82570-Calcium/Creatinine Ratio LC,4020115,CDM,301,RC,82570,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,3.576,fee schedule,110% of LA custom fee schedule,5.18,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,23.408,percent of total billed charges,38% of total billed charges,5.18,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1490.94,3142,
Assay of Urine Creatinine,4020115,CDM,301,RC,82570,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,10.992,fee schedule,110% of LA custom fee schedule,5.18,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,51.68,percent of total billed charges,38% of total billed charges,5.18,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1491.94,3143,
Creatinine Clearance LC,4020117,CDM,301,RC,82575,HCPCS,OUTPATIENT,,,54,32.4,,45.9,85,,36.72,Percent of total billed charges,85% of total billed charges,44.04,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,44.04,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,10.41,110,,7.416,fee schedule,110% of LA custom fee schedule,9.46,100,,7.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.52,38,,22.192,percent of total billed charges,38% of total billed charges,9.46,100,,9.28,Fee Schedule,100% of LA custom fee schedule,1492.94,3144,
VITAMIN B 12,4020119,CDM,301,RC,82607,HCPCS,OUTPATIENT,,,85.4,51.24,,72.59,85,,58.072,Percent of total billed charges,85% of total billed charges,70.28,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.28,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,16.59,110,,3.576,fee schedule,110% of LA custom fee schedule,15.08,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.45,38,,19.76,percent of total billed charges,38% of total billed charges,15.08,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1493.94,3145,
Vitamin B12 Level,4020119,CDM,300,RC,82607,HCPCS,OUTPATIENT,,,85.4,51.24,,72.59,85,,58.072,Percent of total billed charges,85% of total billed charges,70.28,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.28,136.6,,39.6,fee schedule,136.60% of BCBS custom fee schedule,16.59,110,,10.736,fee schedule,110% of LA custom fee schedule,15.08,100,,10.736,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.45,38,,40.128,percent of total billed charges,38% of total billed charges,15.08,100,,13.44,Fee Schedule,100% of LA custom fee schedule,1494.94,3146,
Dehydroepiandrosterone Sulfate LC,4020120,CDM,301,RC,82627,HCPCS,OUTPATIENT,,,223,133.8,,189.55,85,,151.64,Percent of total billed charges,85% of total billed charges,103.67,136.6,,39.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,103.67,136.6,,166.4,fee schedule,136.60% of BCBS custom fee schedule,24.45,110,,10.224,fee schedule,110% of LA custom fee schedule,22.23,100,,10.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,84.74,38,,27.056,percent of total billed charges,38% of total billed charges,22.23,100,,12.8,Fee Schedule,100% of LA custom fee schedule,1495.94,3147,
"Calcitriol(1,25 di-OH Vit D) LC",4020121,CDM,301,RC,82652,HCPCS,OUTPATIENT,,,155,93,,131.75,85,,105.4,Percent of total billed charges,85% of total billed charges,179.44,136.6,,166.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,179.44,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,22.57,110,,5.112,fee schedule,110% of LA custom fee schedule,20.52,100,,5.112,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,58.9,38,,27.056,percent of total billed charges,38% of total billed charges,20.52,100,,6.4,Fee Schedule,100% of LA custom fee schedule,1496.94,3148,
"Pancreatic Elastase, Fecal LC",4020122,CDM,301,RC,82656,HCPCS,OUTPATIENT,,,79,47.4,,67.15,85,,53.72,Percent of total billed charges,85% of total billed charges,53.78,136.6,,17.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.78,136.6,,28.8,fee schedule,136.60% of BCBS custom fee schedule,12.68,110,,2.304,fee schedule,110% of LA custom fee schedule,11.53,100,,2.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.02,38,,55.328,percent of total billed charges,38% of total billed charges,11.53,100,,2.88,Fee Schedule,100% of LA custom fee schedule,1497.94,3149,
Estradiol LC,4020123,CDM,301,RC,82670,HCPCS,OUTPATIENT,,,158.32,94.992,,134.57,85,,107.656,Percent of total billed charges,85% of total billed charges,130.29,136.6,,28.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,130.29,136.6,,105.6,fee schedule,136.60% of BCBS custom fee schedule,30.73,110,,2.304,fee schedule,110% of LA custom fee schedule,27.94,100,,2.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.16,38,,55.328,percent of total billed charges,38% of total billed charges,27.94,100,,2.88,Fee Schedule,100% of LA custom fee schedule,1498.94,3150,
"Estrogens, Total LC",4020124,CDM,301,RC,82672,HCPCS,OUTPATIENT,,,123,73.8,,104.55,85,,83.64,Percent of total billed charges,85% of total billed charges,101.1,136.6,,105.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,101.1,136.6,,184,fee schedule,136.60% of BCBS custom fee schedule,23.87,110,,87.416,fee schedule,110% of LA custom fee schedule,21.7,100,,87.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,46.74,38,,27.36,percent of total billed charges,38% of total billed charges,21.7,100,,109.44,Fee Schedule,100% of LA custom fee schedule,1499.94,3151,
"Estriol, Serum LC",4020125,CDM,301,RC,82677,HCPCS,OUTPATIENT,,,137,82.2,,116.45,85,,93.16,Percent of total billed charges,85% of total billed charges,112.76,136.6,,184,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,112.76,136.6,,140,fee schedule,136.60% of BCBS custom fee schedule,26.6,110,,2.56,fee schedule,110% of LA custom fee schedule,24.18,100,,2.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,52.06,38,,27.36,percent of total billed charges,38% of total billed charges,24.18,100,,3.2,Fee Schedule,100% of LA custom fee schedule,1500.94,3152,
Estrone LC,4020126,CDM,301,RC,82679,HCPCS,OUTPATIENT,,,196,117.6,,166.6,85,,133.28,Percent of total billed charges,85% of total billed charges,116.4,136.6,,140,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,116.4,136.6,,183.6,fee schedule,136.60% of BCBS custom fee schedule,27.45,110,,10.48,fee schedule,110% of LA custom fee schedule,24.95,100,,10.48,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,74.48,38,,70.184,percent of total billed charges,38% of total billed charges,24.95,100,,13.12,Fee Schedule,100% of LA custom fee schedule,1501.94,3153,
FERRITIN,4020127,CDM,301,RC,82728,HCPCS,OUTPATIENT,,,77,46.2,,65.45,85,,52.36,Percent of total billed charges,85% of total billed charges,63.49,136.6,,183.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.49,136.6,,41.6,fee schedule,136.60% of BCBS custom fee schedule,14.99,110,,3.576,fee schedule,110% of LA custom fee schedule,13.63,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.26,38,,24.584,percent of total billed charges,38% of total billed charges,13.63,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1502.94,3154,
FOLIC ACID; SERUM,4020128,CDM,301,RC,82746,HCPCS,OUTPATIENT,,,83,49.8,,70.55,85,,56.44,Percent of total billed charges,85% of total billed charges,68.53,136.6,,41.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,68.53,136.6,,46.8,fee schedule,136.60% of BCBS custom fee schedule,16.17,110,,24.04,fee schedule,110% of LA custom fee schedule,14.7,100,,1027.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.54,38,,24.584,percent of total billed charges,38% of total billed charges,14.7,100,,21.856,Fee Schedule,100% of LA custom fee schedule,1503.94,3155,
Folic Acid Level,4020128,CDM,300,RC,82746,HCPCS,OUTPATIENT,,,83,49.8,,70.55,85,,56.44,Percent of total billed charges,85% of total billed charges,68.53,136.6,,46.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,68.53,136.6,,54.8,fee schedule,136.60% of BCBS custom fee schedule,16.17,110,,2.56,fee schedule,110% of LA custom fee schedule,14.7,100,,2.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.54,38,,144.4,percent of total billed charges,38% of total billed charges,14.7,100,,3.2,Fee Schedule,100% of LA custom fee schedule,1504.94,3156,
"Folate, RBC LC",4020129,CDM,309,RC,1-82747|2-,HCPCS,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,54.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,1161.2,percent of total billed charges,50% of total billed charges,42.81,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,156.864,percent of total billed charges,38% of total billed charges,53.6,40,,14.4,percent of total billed charges,40% of total billed charges,1505.94,3157,
"Immunoglobulins A/E/G/M, Serum LC",4020130,CDM,301,RC,1-82784|2-,HCPCS,OUTPATIENT,,,256,153.6,,217.6,85,,174.08,Percent of total billed charges,85% of total billed charges,128,50,,1161.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,128,50,,1308,percent of total billed charges,50% of total billed charges,81.79,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,81.79,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,97.28,38,,12.88,percent of total billed charges,38% of total billed charges,102.4,40,,16.32,percent of total billed charges,40% of total billed charges,1506.94,3158,
"IgG, Subclasses(1-4) LC",4020131,CDM,301,RC,82784,HCPCS,OUTPATIENT,,,560,336,,476,85,,380.8,Percent of total billed charges,85% of total billed charges,43.36,136.6,,1308,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.36,136.6,,197.6,fee schedule,136.60% of BCBS custom fee schedule,10.23,110,,67.224,fee schedule,110% of LA custom fee schedule,9.3,100,,67.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,212.8,38,,12.88,percent of total billed charges,38% of total billed charges,9.3,100,,84.16,Fee Schedule,100% of LA custom fee schedule,1507.94,3159,
"Immunoglobulin M, Qn, Serum LC",4020134,CDM,301,RC,82784,HCPCS,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,43.36,136.6,,197.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.36,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,10.23,110,,0.512,fee schedule,110% of LA custom fee schedule,9.3,100,,0.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.14,38,,469.984,percent of total billed charges,38% of total billed charges,9.3,100,,0.64,Fee Schedule,100% of LA custom fee schedule,1508.94,3160,
"Immunoglobulin A, Quant. Serum LC",4020134,CDM,301,RC,82784,HCPCS,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,43.36,136.6,,4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.36,136.6,,215.2,fee schedule,136.60% of BCBS custom fee schedule,10.23,110,,2.048,fee schedule,110% of LA custom fee schedule,9.3,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.14,38,,17.632,percent of total billed charges,38% of total billed charges,9.3,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1509.94,3161,
"Immunoglobulin E, Total LC",4020137,CDM,301,RC,82785,HCPCS,OUTPATIENT,,,93.28,55.968,,79.29,85,,63.432,Percent of total billed charges,85% of total billed charges,76.77,136.6,,215.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76.77,136.6,,2322,fee schedule,136.60% of BCBS custom fee schedule,18.11,110,,57.768,fee schedule,110% of LA custom fee schedule,16.46,100,,57.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.45,38,,16.416,percent of total billed charges,38% of total billed charges,16.46,100,,72.32,Fee Schedule,100% of LA custom fee schedule,1510.94,3162,
VENOUS PH,4020140,CDM,301,RC,82800,HCPCS,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,39.48,136.6,,2322,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.48,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,11.98,110,,0.408,fee schedule,110% of LA custom fee schedule,10.89,100,,0.408,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,19.76,percent of total billed charges,38% of total billed charges,10.89,100,,0.512,Fee Schedule,100% of LA custom fee schedule,1511.94,3163,
VENOUS PH,4020140,CDM,301,RC,82800,HCPCS,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,39.48,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.48,136.6,,155.6,fee schedule,136.60% of BCBS custom fee schedule,11.98,110,,13.288,fee schedule,110% of LA custom fee schedule,10.89,100,,13.288,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,14.896,percent of total billed charges,38% of total billed charges,10.89,100,,16.64,Fee Schedule,100% of LA custom fee schedule,1512.94,3164,
ARTERIAL BLOOD GAS  82803,4020141,CDM,301,RC,82803,HCPCS,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,24.27,136.6,,155.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.27,136.6,,1320,fee schedule,136.60% of BCBS custom fee schedule,6.99,110,,1.792,fee schedule,110% of LA custom fee schedule,6.35,100,,1.792,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.64,38,,14.896,percent of total billed charges,38% of total billed charges,6.35,100,,2.24,Fee Schedule,100% of LA custom fee schedule,1513.94,3165,
Arterial Blood Gas,4020141,CDM,301,RC,82803,HCPCS,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,24.27,136.6,,1320,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.27,136.6,,168,fee schedule,136.60% of BCBS custom fee schedule,6.99,110,,17.32,fee schedule,110% of LA custom fee schedule,6.35,100,,17.32,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.64,38,,14.896,percent of total billed charges,38% of total billed charges,6.35,100,,21.68,Fee Schedule,100% of LA custom fee schedule,1514.94,3166,
"Gastrin, Serum LC",4020143,CDM,300,RC,82941,HCPCS,OUTPATIENT,,,97,58.2,,82.45,85,,65.96,Percent of total billed charges,85% of total billed charges,82.21,136.6,,168,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.21,136.6,,168,fee schedule,136.60% of BCBS custom fee schedule,19.39,110,,5.368,fee schedule,110% of LA custom fee schedule,17.63,100,,5.368,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.86,38,,26.448,percent of total billed charges,38% of total billed charges,17.63,100,,6.72,Fee Schedule,100% of LA custom fee schedule,1515.94,3167,
"Glucose, Body Fluid LC",4020145,CDM,301,RC,82945,HCPCS,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,18.29,136.6,,168,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.29,136.6,,1194,fee schedule,136.60% of BCBS custom fee schedule,4.32,110,,0.768,fee schedule,110% of LA custom fee schedule,3.93,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.06,38,,18.24,percent of total billed charges,38% of total billed charges,3.93,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1516.94,3168,
"Glucose, Cerebrospinal Fluid LC",4020146,CDM,301,RC,82945,HCPCS,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,18.29,136.6,,1194,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.29,136.6,,30,fee schedule,136.60% of BCBS custom fee schedule,4.32,110,,11.248,fee schedule,110% of LA custom fee schedule,3.93,100,,11.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.36,38,,26.448,percent of total billed charges,38% of total billed charges,3.93,100,,14.08,Fee Schedule,100% of LA custom fee schedule,1517.94,3169,
GLU; QUAN BLD,4020147,CDM,301,RC,82947,HCPCS,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,18.29,136.6,,30,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.29,136.6,,26.4,fee schedule,136.60% of BCBS custom fee schedule,4.32,110,,7.672,fee schedule,110% of LA custom fee schedule,3.93,100,,7.672,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.36,38,,16.416,percent of total billed charges,38% of total billed charges,3.93,100,,9.6,Fee Schedule,100% of LA custom fee schedule,1518.94,3170,
Glucose Fingerstick POC,4020147,CDM,300,RC,82947,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,18.29,136.6,,26.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.29,136.6,,78,fee schedule,136.60% of BCBS custom fee schedule,4.32,110,,2.808,fee schedule,110% of LA custom fee schedule,3.93,100,,2.808,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,13.984,percent of total billed charges,38% of total billed charges,3.93,100,,3.52,Fee Schedule,100% of LA custom fee schedule,1519.94,3171,
"Glucose; quantitative, blood (except reagent strip)",4020147,CDM,301,RC,82947,HCPCS,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,18.29,136.6,,78,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.29,136.6,,215.2,fee schedule,136.60% of BCBS custom fee schedule,4.32,110,,3.576,fee schedule,110% of LA custom fee schedule,3.93,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.36,38,,13.68,percent of total billed charges,38% of total billed charges,3.93,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1520.94,3172,
Blood Glucose Monitoring,4020148,CDM,301,RC,82948,HCPCS,OUTPATIENT,,,32,19.2,91,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,14.78,136.6,,215.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.78,136.6,,251.6,fee schedule,136.60% of BCBS custom fee schedule,4.48,110,,8.176,fee schedule,110% of LA custom fee schedule,4.07,100,,8.176,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.16,38,,13.68,percent of total billed charges,38% of total billed charges,4.07,100,,10.24,Fee Schedule,100% of LA custom fee schedule,1521.94,3173,
GTT-1 Hr,4020151,CDM,301,RC,82950,HCPCS,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,22.16,136.6,,251.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.16,136.6,,104,fee schedule,136.60% of BCBS custom fee schedule,5.23,110,,5.368,fee schedule,110% of LA custom fee schedule,4.75,100,,5.368,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.26,38,,13.984,percent of total billed charges,38% of total billed charges,4.75,100,,6.72,Fee Schedule,100% of LA custom fee schedule,1522.94,3174,
GTT-2 Hr,4020152,CDM,301,RC,1-82950|2-,HCPCS,OUTPATIENT,,,64,38.4,,54.4,85,,43.52,Percent of total billed charges,85% of total billed charges,32,50,,104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32,50,,104,percent of total billed charges,50% of total billed charges,20.45,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,20.45,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.32,38,,19.456,percent of total billed charges,38% of total billed charges,25.6,40,,3.84,percent of total billed charges,40% of total billed charges,1523.94,3175,
.GTT-3 Hr,4020153,CDM,301,RC,82951,HCPCS,OUTPATIENT,,,73,43.8,,62.05,85,,49.64,Percent of total billed charges,85% of total billed charges,60.04,136.6,,104,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.04,136.6,,478.8,fee schedule,136.60% of BCBS custom fee schedule,14.16,110,,2.808,fee schedule,110% of LA custom fee schedule,12.87,100,,2.808,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.74,38,,13.68,percent of total billed charges,38% of total billed charges,12.87,100,,3.52,Fee Schedule,100% of LA custom fee schedule,1524.94,3176,
.GTT-4 Hr,4020154,CDM,301,RC,82951,HCPCS,OUTPATIENT,,,138,82.8,,117.3,85,,93.84,Percent of total billed charges,85% of total billed charges,60.04,136.6,,478.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.04,136.6,,104,fee schedule,136.60% of BCBS custom fee schedule,14.16,110,,3.576,fee schedule,110% of LA custom fee schedule,12.87,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,52.44,38,,13.944,percent of total billed charges,38% of total billed charges,12.87,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1525.94,3177,
.GTT-5 Hr,4020155,CDM,301,RC,82951,HCPCS,OUTPATIENT,,,162,97.2,,137.7,85,,110.16,Percent of total billed charges,85% of total billed charges,60.04,136.6,,104,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.04,136.6,,77.2,fee schedule,136.60% of BCBS custom fee schedule,14.16,110,,9.456,fee schedule,110% of LA custom fee schedule,12.87,100,,9.456,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,61.56,38,,12.16,percent of total billed charges,38% of total billed charges,12.87,100,,11.84,Fee Schedule,100% of LA custom fee schedule,1526.94,3178,
Blood Glucose Monitoring,4020157,CDM,300,RC,82962,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,10.91,136.6,,77.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.91,136.6,,69.2,fee schedule,136.60% of BCBS custom fee schedule,3.59,110,,7.16,fee schedule,110% of LA custom fee schedule,3.26,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,22.496,percent of total billed charges,38% of total billed charges,3.26,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1527.94,3179,
GGT LC,4020158,CDM,309,RC,82977,HCPCS,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,33.58,136.6,,69.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,33.58,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,7.92,110,,10.224,fee schedule,110% of LA custom fee schedule,7.2,100,,10.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.62,38,,15.2,percent of total billed charges,38% of total billed charges,7.2,100,,12.8,Fee Schedule,100% of LA custom fee schedule,1528.94,3180,
"Glutamyltransferase, gamma (GGT)",4020158,CDM,309,RC,82977,HCPCS,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,33.58,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,33.58,136.6,,2520,fee schedule,136.60% of BCBS custom fee schedule,7.92,110,,2.048,fee schedule,110% of LA custom fee schedule,7.2,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.62,38,,60.8,percent of total billed charges,38% of total billed charges,7.2,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1529.94,3181,
Fructosamine LC,4020160,CDM,301,RC,82985,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,70.28,136.6,,2520,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.28,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,18.44,110,,6.648,fee schedule,110% of LA custom fee schedule,16.76,100,,6.648,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.3,38,,17.936,percent of total billed charges,38% of total billed charges,16.76,100,,8.32,Fee Schedule,100% of LA custom fee schedule,1530.94,3182,
Glycated Albumin LC,4020160,CDM,301,RC,82985,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,70.28,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.28,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,18.44,110,,5.624,fee schedule,110% of LA custom fee schedule,16.76,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.3,38,,17.936,percent of total billed charges,38% of total billed charges,16.76,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1531.94,3183,
"FSH, Serum LC",4020161,CDM,301,RC,83001,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,86.66,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,86.66,136.6,,29.2,fee schedule,136.60% of BCBS custom fee schedule,20.44,110,,2.808,fee schedule,110% of LA custom fee schedule,18.58,100,,2.808,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.9,38,,18.24,percent of total billed charges,38% of total billed charges,18.58,100,,3.52,Fee Schedule,100% of LA custom fee schedule,1532.94,3184,
"Luteinizing Hormone(LH), S LC",4020162,CDM,301,RC,83002,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,86.36,136.6,,29.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,86.36,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,20.37,110,,10.736,fee schedule,110% of LA custom fee schedule,18.52,100,,10.736,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.9,38,,7.296,percent of total billed charges,38% of total billed charges,18.52,100,,13.44,Fee Schedule,100% of LA custom fee schedule,1533.94,3185,
"Growth Hormone, Serum LC",4020163,CDM,301,RC,83003,HCPCS,OUTPATIENT,,,454,272.4,,385.9,85,,308.72,Percent of total billed charges,85% of total billed charges,77.71,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.71,136.6,,2280,fee schedule,136.60% of BCBS custom fee schedule,18.34,110,,0.432,fee schedule,110% of LA custom fee schedule,16.67,100,,0.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,172.52,38,,58.368,percent of total billed charges,38% of total billed charges,16.67,100,,0.544,Fee Schedule,100% of LA custom fee schedule,1534.94,3186,
Haptoglobin LC,4020164,CDM,301,RC,83010,HCPCS,OUTPATIENT,,,71,42.6,,60.35,85,,48.28,Percent of total billed charges,85% of total billed charges,58.68,136.6,,2280,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,58.68,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,13.84,110,,1.28,fee schedule,110% of LA custom fee schedule,12.58,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,26.98,38,,20.672,percent of total billed charges,38% of total billed charges,12.58,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1535.94,3187,
Haptoglobin; quantitative,4020164,CDM,301,RC,83010,HCPCS,OUTPATIENT,,,71,42.6,,60.35,85,,48.28,Percent of total billed charges,85% of total billed charges,58.68,136.6,,11.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,58.68,136.6,,504.4,fee schedule,136.60% of BCBS custom fee schedule,13.84,110,,8.688,fee schedule,110% of LA custom fee schedule,12.58,100,,8.688,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,26.98,38,,20.672,percent of total billed charges,38% of total billed charges,12.58,100,,10.88,Fee Schedule,100% of LA custom fee schedule,1536.94,3188,
Hemoglobinopathy Fractionation Cascade LC,4020164,CDM,301,RC,83020,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,60.04,136.6,,504.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.04,136.6,,300,fee schedule,136.60% of BCBS custom fee schedule,14.16,110,,8.176,fee schedule,110% of LA custom fee schedule,12.87,100,,8.176,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,20.672,percent of total billed charges,38% of total billed charges,12.87,100,,10.24,Fee Schedule,100% of LA custom fee schedule,1537.94,3189,
H. pylori Breath Test LC,4020165,CDM,301,RC,83013,HCPCS,OUTPATIENT,,,324,194.4,,275.4,85,,220.32,Percent of total billed charges,85% of total billed charges,134.93,136.6,,300,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,134.93,136.6,,258,fee schedule,136.60% of BCBS custom fee schedule,44.3,110,,16.104,fee schedule,110% of LA custom fee schedule,40.27,100,,16.104,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,123.12,38,,24.928,percent of total billed charges,38% of total billed charges,40.27,100,,20.16,Fee Schedule,100% of LA custom fee schedule,1538.94,3190,
H. Pylori Drug Admin,4020166,CDM,301,RC,83014,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,36.64,136.6,,258,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.64,136.6,,344.4,fee schedule,136.60% of BCBS custom fee schedule,8.65,110,,16.104,fee schedule,110% of LA custom fee schedule,7.86,100,,16.104,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.1,38,,24.928,percent of total billed charges,38% of total billed charges,7.86,100,,20.16,Fee Schedule,100% of LA custom fee schedule,1539.94,3191,
Hgb Frac. w/o Solubility LC,4020168,CDM,301,RC,83021,HCPCS,OUTPATIENT,,,102,61.2,,86.7,85,,69.36,Percent of total billed charges,85% of total billed charges,84.19,136.6,,344.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.19,136.6,,540,fee schedule,136.60% of BCBS custom fee schedule,19.87,110,,7.672,fee schedule,110% of LA custom fee schedule,18.06,100,,7.672,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38.76,38,,24.928,percent of total billed charges,38% of total billed charges,18.06,100,,9.6,Fee Schedule,100% of LA custom fee schedule,1540.94,3192,
HGB A1C,4020169,CDM,301,RC,83036,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,45.26,136.6,,540,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.26,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,10.68,110,,15.848,fee schedule,110% of LA custom fee schedule,9.71,100,,15.848,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.9,38,,29.792,percent of total billed charges,38% of total billed charges,9.71,100,,19.84,Fee Schedule,100% of LA custom fee schedule,1541.94,3193,
Hemoglobin A1c POC,4020169,CDM,300,RC,83036,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,45.26,136.6,,18.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.26,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,10.68,110,,7.92,fee schedule,110% of LA custom fee schedule,9.71,100,,7.92,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,22.496,percent of total billed charges,38% of total billed charges,9.71,100,,9.92,Fee Schedule,100% of LA custom fee schedule,1542.94,3194,
"Homocyst(e)ine, Plasma LC",4020170,CDM,301,RC,83090,HCPCS,OUTPATIENT,,,104,62.4,,88.4,85,,70.72,Percent of total billed charges,85% of total billed charges,78.64,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.64,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,19.71,110,,8.688,fee schedule,110% of LA custom fee schedule,17.92,100,,8.688,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.52,38,,49.856,percent of total billed charges,38% of total billed charges,17.92,100,,10.88,Fee Schedule,100% of LA custom fee schedule,1543.94,3195,
17-OH Progesterone LC,4020173,CDM,301,RC,83498,HCPCS,OUTPATIENT,,,154,92.4,,130.9,85,,104.72,Percent of total billed charges,85% of total billed charges,126.64,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,126.64,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,29.89,110,,10.44,fee schedule,110% of LA custom fee schedule,27.17,100,,10.44,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,58.52,38,,20.656,percent of total billed charges,38% of total billed charges,27.17,100,,13.072,Fee Schedule,100% of LA custom fee schedule,1544.94,3196,
86037 ANCA Profile LC,4020174,CDM,302,RC,86037,HCPCS,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,33.95,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,33.95,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,9.94,110,,1.024,fee schedule,110% of LA custom fee schedule,9.04,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.2,38,,24.928,percent of total billed charges,38% of total billed charges,9.04,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1545.94,3197,
Mitochondrial (M2) Antibody LC,4020175,CDM,302,RC,86381,HCPCS,OUTPATIENT,,,76,45.6,,64.6,85,,51.68,Percent of total billed charges,85% of total billed charges,71.67,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,71.67,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,21,110,,11.76,fee schedule,110% of LA custom fee schedule,19.09,100,,11.76,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.88,38,,24.928,percent of total billed charges,38% of total billed charges,19.09,100,,14.72,Fee Schedule,100% of LA custom fee schedule,1546.94,3198,
Adrenal 21-Hydroxylase Autoantibodies LC,4020175,CDM,300,RC,83516,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,53.78,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.78,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,12.68,110,,11.248,fee schedule,110% of LA custom fee schedule,11.53,100,,11.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.7,38,,20.672,percent of total billed charges,38% of total billed charges,11.53,100,,14.08,Fee Schedule,100% of LA custom fee schedule,1547.94,3199,
83516 ANCA Profile LC,4020175,CDM,302,RC,83516,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,53.78,136.6,,22.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.78,136.6,,285.2,fee schedule,136.60% of BCBS custom fee schedule,12.68,110,,6.136,fee schedule,110% of LA custom fee schedule,11.53,100,,6.136,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.7,38,,72.96,percent of total billed charges,38% of total billed charges,11.53,100,,7.68,Fee Schedule,100% of LA custom fee schedule,1548.94,3200,
t-Transglutaminase (tTG) IgG LC,4020176,CDM,302,RC,86364,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,32.48,136.6,,285.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.48,136.6,,228,fee schedule,136.60% of BCBS custom fee schedule,9.52,110,,24.464,fee schedule,110% of LA custom fee schedule,8.65,100,,1032.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,72.96,percent of total billed charges,38% of total billed charges,8.65,100,,22.24,Fee Schedule,100% of LA custom fee schedule,1549.94,3201,
t-Transglutaminase (tTG) IgA LC,4020177,CDM,302,RC,86364,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,32.48,136.6,,228,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.48,136.6,,232.8,fee schedule,136.60% of BCBS custom fee schedule,9.52,110,,3.936,fee schedule,110% of LA custom fee schedule,8.65,100,,1150.2,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,53.808,percent of total billed charges,38% of total billed charges,8.65,100,,3.576,Fee Schedule,100% of LA custom fee schedule,1550.94,3202,
AChR Binding Abs LC,4020178,CDM,301,RC,83519,HCPCS,OUTPATIENT,,,92,55.2,,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,21.71,136.6,,232.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.71,136.6,,618,fee schedule,136.60% of BCBS custom fee schedule,6.25,110,,7.416,fee schedule,110% of LA custom fee schedule,5.68,100,,7.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.96,38,,52.896,percent of total billed charges,38% of total billed charges,5.68,100,,9.28,Fee Schedule,100% of LA custom fee schedule,1551.94,3203,
"Thyrotropin Receptor Ab, Serum LC",4020180,CDM,302,RC,83520,HCPCS,OUTPATIENT,,,88,52.8,,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,60.38,136.6,,618,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.38,136.6,,554.8,fee schedule,136.60% of BCBS custom fee schedule,16.32,110,,8.944,fee schedule,110% of LA custom fee schedule,14.84,100,,8.944,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.44,38,,89.072,percent of total billed charges,38% of total billed charges,14.84,100,,11.2,Fee Schedule,100% of LA custom fee schedule,1552.94,3204,
Insulin LC,4020181,CDM,301,RC,83525,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,53.31,136.6,,554.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.31,136.6,,2500,fee schedule,136.60% of BCBS custom fee schedule,12.57,110,,7.92,fee schedule,110% of LA custom fee schedule,11.43,100,,7.92,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.7,38,,89.072,percent of total billed charges,38% of total billed charges,11.43,100,,9.92,Fee Schedule,100% of LA custom fee schedule,1553.94,3205,
ASSAY OF IRON  83540,4020182,CDM,301,RC,83540,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,25.01,136.6,,2500,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.01,136.6,,404,fee schedule,136.60% of BCBS custom fee schedule,6.97,110,,7.416,fee schedule,110% of LA custom fee schedule,6.34,100,,7.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.1,38,,89.072,percent of total billed charges,38% of total billed charges,6.34,100,,9.28,Fee Schedule,100% of LA custom fee schedule,1554.94,3206,
Total Iron Binding,4020183,CDM,301,RC,83550,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,40.73,136.6,,404,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.73,136.6,,212,fee schedule,136.60% of BCBS custom fee schedule,9.61,110,,3.832,fee schedule,110% of LA custom fee schedule,8.74,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,60.496,percent of total billed charges,38% of total billed charges,8.74,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1555.94,3207,
LACTIC ACID PLASMA,4020184,CDM,301,RC,83605,HCPCS,OUTPATIENT,,,89,53.4,,75.65,85,,60.52,Percent of total billed charges,85% of total billed charges,49.76,136.6,,212,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.76,136.6,,1286.8,fee schedule,136.60% of BCBS custom fee schedule,12.73,110,,7.16,fee schedule,110% of LA custom fee schedule,11.57,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.82,38,,146.552,percent of total billed charges,38% of total billed charges,11.57,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1556.94,3208,
Lactate Dehydrogenase,4020185,CDM,301,RC,83615,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,28.17,136.6,,1286.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.17,136.6,,645.6,fee schedule,136.60% of BCBS custom fee schedule,6.64,110,,49.072,fee schedule,110% of LA custom fee schedule,6.04,100,,49.072,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,46.816,percent of total billed charges,38% of total billed charges,6.04,100,,61.44,Fee Schedule,100% of LA custom fee schedule,1557.94,3209,
LDH LC,4020185,CDM,301,RC,83615,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,28.17,136.6,,645.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.17,136.6,,28.4,fee schedule,136.60% of BCBS custom fee schedule,6.64,110,,0.768,fee schedule,110% of LA custom fee schedule,6.04,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,46.816,percent of total billed charges,38% of total billed charges,6.04,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1558.94,3210,
"LD, Body Fluid LC",4020186,CDM,301,RC,83615,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,28.17,136.6,,28.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.17,136.6,,28.4,fee schedule,136.60% of BCBS custom fee schedule,6.64,110,,1.024,fee schedule,110% of LA custom fee schedule,6.04,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,72.96,percent of total billed charges,38% of total billed charges,6.04,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1559.94,3211,
"LDH,Body fluid",4020186,CDM,301,RC,83615,HCPCS,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,28.17,136.6,,28.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.17,136.6,,524.8,fee schedule,136.60% of BCBS custom fee schedule,6.64,110,,51.632,fee schedule,110% of LA custom fee schedule,6.04,100,,51.632,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.58,38,,72.96,percent of total billed charges,38% of total billed charges,6.04,100,,64.64,Fee Schedule,100% of LA custom fee schedule,1560.94,3212,
"Lead, Blood (Adult) LC",4020188,CDM,309,RC,83655,HCPCS,OUTPATIENT,,,83,49.8,,70.55,85,,56.44,Percent of total billed charges,85% of total billed charges,56.43,136.6,,524.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.43,136.6,,19.6,fee schedule,136.60% of BCBS custom fee schedule,13.32,110,,19.936,fee schedule,110% of LA custom fee schedule,12.11,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.54,38,,41.496,percent of total billed charges,38% of total billed charges,12.11,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1561.94,3213,
LIPASE,4020190,CDM,301,RC,83690,HCPCS,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,32.1,136.6,,19.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.1,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,7.58,110,,13.8,fee schedule,110% of LA custom fee schedule,6.89,100,,13.8,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.82,38,,41.496,percent of total billed charges,38% of total billed charges,6.89,100,,17.28,Fee Schedule,100% of LA custom fee schedule,1562.94,3214,
Lipoprotein (A) LC,4020191,CDM,301,RC,83695,HCPCS,OUTPATIENT,,,73.36,44.016,,62.36,85,,49.888,Percent of total billed charges,85% of total billed charges,50.94,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.94,136.6,,24.4,fee schedule,136.60% of BCBS custom fee schedule,15.75,110,,40.64,fee schedule,110% of LA custom fee schedule,14.32,100,,40.64,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.88,38,,41.496,percent of total billed charges,38% of total billed charges,14.32,100,,50.88,Fee Schedule,100% of LA custom fee schedule,1563.94,3215,
LIPORPROTEIN DIRECT ME,4020194,CDM,301,RC,83718,HCPCS,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,38.17,136.6,,24.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,38.17,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,9.01,110,,3.32,fee schedule,110% of LA custom fee schedule,8.19,100,,3.32,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.48,38,,88.768,percent of total billed charges,38% of total billed charges,8.19,100,,4.16,Fee Schedule,100% of LA custom fee schedule,1564.94,3216,
MAGNESIUM,4020195,CDM,301,RC,83735,HCPCS,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,31.23,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,31.23,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,7.37,110,,1.536,fee schedule,110% of LA custom fee schedule,6.7,100,,1.536,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.44,38,,88.768,percent of total billed charges,38% of total billed charges,6.7,100,,1.92,Fee Schedule,100% of LA custom fee schedule,1565.94,3217,
"Metanephrines, Frac, Qn, 24-Hr LC",4020200,CDM,301,RC,83835,HCPCS,OUTPATIENT,,,96,57.6,,81.6,85,,65.28,Percent of total billed charges,85% of total billed charges,78.97,136.6,,2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.97,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,18.63,110,,11.504,fee schedule,110% of LA custom fee schedule,16.94,100,,11.504,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.48,38,,41.32,percent of total billed charges,38% of total billed charges,16.94,100,,14.4,Fee Schedule,100% of LA custom fee schedule,1566.94,3218,
"Metanephrines, Frac., Pl. Free",4020200,CDM,301,RC,83835,HCPCS,OUTPATIENT,,,96,57.6,,81.6,85,,65.28,Percent of total billed charges,85% of total billed charges,78.97,136.6,,2.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.97,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,18.63,110,,10.992,fee schedule,110% of LA custom fee schedule,16.94,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.48,38,,10.64,percent of total billed charges,38% of total billed charges,16.94,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1567.94,3219,
"Myoglobin, Serum LC",4020201,CDM,301,RC,83874,HCPCS,OUTPATIENT,,,73,43.8,,62.05,85,,49.64,Percent of total billed charges,85% of total billed charges,60.2,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.2,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,13.52,110,,16.36,fee schedule,110% of LA custom fee schedule,12.29,100,,16.36,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.74,38,,20.656,percent of total billed charges,38% of total billed charges,12.29,100,,20.48,Fee Schedule,100% of LA custom fee schedule,1568.94,3220,
PRO-BRAIN NATRIURETIC PEPTIDE,4020203,CDM,301,RC,83880,HCPCS,OUTPATIENT,,,193,115.8,,164.05,85,,131.24,Percent of total billed charges,85% of total billed charges,158.26,136.6,,15.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,158.26,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,43.19,110,,11.76,fee schedule,110% of LA custom fee schedule,39.26,100,,11.76,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,73.34,38,,37.392,percent of total billed charges,38% of total billed charges,39.26,100,,14.72,Fee Schedule,100% of LA custom fee schedule,1569.94,3221,
"Methylmalonic Acid, Serum LC",4020211,CDM,301,RC,83921,HCPCS,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,76.76,136.6,,3.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76.76,136.6,,318,fee schedule,136.60% of BCBS custom fee schedule,23.33,110,,11.76,fee schedule,110% of LA custom fee schedule,21.21,100,,11.76,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.56,38,,17.632,percent of total billed charges,38% of total billed charges,21.21,100,,14.72,Fee Schedule,100% of LA custom fee schedule,1570.94,3222,
Osmolality LC,4020213,CDM,301,RC,83930,HCPCS,OUTPATIENT,,,37.44,22.464,,31.82,85,,25.456,Percent of total billed charges,85% of total billed charges,30.83,136.6,,318,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.83,136.6,,210,fee schedule,136.60% of BCBS custom fee schedule,7.27,110,,10.992,fee schedule,110% of LA custom fee schedule,6.61,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.23,38,,20.672,percent of total billed charges,38% of total billed charges,6.61,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1571.94,3223,
"Osmolality, Urine LC",4020214,CDM,301,RC,83935,HCPCS,OUTPATIENT,,,38.6,23.16,,32.81,85,,26.248,Percent of total billed charges,85% of total billed charges,31.76,136.6,,210,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,31.76,136.6,,917.6,fee schedule,136.60% of BCBS custom fee schedule,7.5,110,,63.648,fee schedule,110% of LA custom fee schedule,6.82,100,,63.648,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.67,38,,11.552,percent of total billed charges,38% of total billed charges,6.82,100,,79.68,Fee Schedule,100% of LA custom fee schedule,1572.94,3224,
"PTH, Intact LC",4020216,CDM,301,RC,83970,HCPCS,OUTPATIENT,,,234,140.4,,198.9,85,,159.12,Percent of total billed charges,85% of total billed charges,192.41,136.6,,917.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,192.41,136.6,,137.6,fee schedule,136.60% of BCBS custom fee schedule,45.41,110,,43.96,fee schedule,110% of LA custom fee schedule,41.28,100,,43.96,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,88.92,38,,9.488,percent of total billed charges,38% of total billed charges,41.28,100,,55.04,Fee Schedule,100% of LA custom fee schedule,1573.94,3225,
"ph, Body Fluid LC",4020217,CDM,301,RC,83986,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,16.68,136.6,,137.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.68,136.6,,56.8,fee schedule,136.60% of BCBS custom fee schedule,3.94,110,,3.832,fee schedule,110% of LA custom fee schedule,3.58,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.5,38,,9.12,percent of total billed charges,38% of total billed charges,3.58,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1574.94,3226,
Calprotectin Fecal LC,4020219,CDM,301,RC,83993,HCPCS,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,77.22,136.6,,56.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.22,136.6,,42,fee schedule,136.60% of BCBS custom fee schedule,21.59,110,,1.792,fee schedule,110% of LA custom fee schedule,19.63,100,,1.792,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,50.92,38,,14.896,percent of total billed charges,38% of total billed charges,19.63,100,,2.24,Fee Schedule,100% of LA custom fee schedule,1575.94,3227,
PHOSPHATASE ALKALINE,4020221,CDM,301,RC,84075,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,24.12,136.6,,42,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,41.6,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,10.224,fee schedule,110% of LA custom fee schedule,5.18,100,,10.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,25.232,percent of total billed charges,38% of total billed charges,5.18,100,,12.8,Fee Schedule,100% of LA custom fee schedule,1576.94,3228,
Bone Specific Alk Phos LC,4020222,CDM,301,RC,84080,HCPCS,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,68.94,136.6,,41.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,68.94,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,16.26,110,,17.128,fee schedule,110% of LA custom fee schedule,14.78,100,,17.128,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.8,38,,46.816,percent of total billed charges,38% of total billed charges,14.78,100,,21.44,Fee Schedule,100% of LA custom fee schedule,1577.94,3229,
PHOSPHORUS INORGANIC,4020223,CDM,301,RC,84100,HCPCS,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,22.14,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.14,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,5.21,110,,0.752,fee schedule,110% of LA custom fee schedule,4.74,100,,0.752,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.26,38,,55.024,percent of total billed charges,38% of total billed charges,4.74,100,,0.944,Fee Schedule,100% of LA custom fee schedule,1578.94,3230,
POTASSIUM; SERUM,4020225,CDM,301,RC,84132,HCPCS,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,21.41,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.41,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,5.24,110,,5.176,fee schedule,110% of LA custom fee schedule,4.76,100,,5.176,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.88,38,,3.648,percent of total billed charges,38% of total billed charges,4.76,100,,6.48,Fee Schedule,100% of LA custom fee schedule,1579.94,3231,
"Potassium, Urine LC",4020226,CDM,301,RC,84133,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,20.05,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.05,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,5.2,110,,19.424,fee schedule,110% of LA custom fee schedule,4.73,100,,19.424,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,3.648,percent of total billed charges,38% of total billed charges,4.73,100,,24.32,Fee Schedule,100% of LA custom fee schedule,1580.94,3232,
PREALBUMIN,4020227,CDM,301,RC,84134,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,26.01,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.01,136.6,,301.6,fee schedule,136.60% of BCBS custom fee schedule,7.49,110,,8.176,fee schedule,110% of LA custom fee schedule,6.81,100,,8.176,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.1,38,,9.12,percent of total billed charges,38% of total billed charges,6.81,100,,10.24,Fee Schedule,100% of LA custom fee schedule,1581.94,3233,
Progesterone LC,4020228,CDM,301,RC,84144,HCPCS,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,97.27,136.6,,301.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,97.27,136.6,,301.6,fee schedule,136.60% of BCBS custom fee schedule,22.95,110,,26.328,fee schedule,110% of LA custom fee schedule,20.86,100,,26.328,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,44.84,38,,128.288,percent of total billed charges,38% of total billed charges,20.86,100,,32.96,Fee Schedule,100% of LA custom fee schedule,1582.94,3234,
Prolactin LC,4020229,CDM,301,RC,84146,HCPCS,OUTPATIENT,,,109.8,65.88,,93.33,85,,74.664,Percent of total billed charges,85% of total billed charges,90.37,136.6,,301.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,90.37,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,21.32,110,,62.88,fee schedule,110% of LA custom fee schedule,19.38,100,,62.88,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.72,38,,28.576,percent of total billed charges,38% of total billed charges,19.38,100,,78.72,Fee Schedule,100% of LA custom fee schedule,1583.94,3235,
PSA TOTAL,4020230,CDM,301,RC,84153,HCPCS,OUTPATIENT,,,104,62.4,,88.4,85,,70.72,Percent of total billed charges,85% of total billed charges,85.76,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,85.76,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,20.23,110,,36.04,fee schedule,110% of LA custom fee schedule,18.39,100,,36.04,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.52,38,,28.88,percent of total billed charges,38% of total billed charges,18.39,100,,45.12,Fee Schedule,100% of LA custom fee schedule,1584.94,3236,
Protein Total,4020232,CDM,309,RC,84155,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,17.08,136.6,,3.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,4.04,110,,120.88,fee schedule,110% of LA custom fee schedule,3.67,100,,120.88,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.98,38,,28.576,percent of total billed charges,38% of total billed charges,3.67,100,,151.344,Fee Schedule,100% of LA custom fee schedule,1585.94,3237,
"PE and FLC, Serum LC",4020232,CDM,309,RC,84155,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,17.08,136.6,,53.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,76.8,fee schedule,136.60% of BCBS custom fee schedule,4.04,110,,134.344,fee schedule,110% of LA custom fee schedule,3.67,100,,134.344,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.98,38,,52.896,percent of total billed charges,38% of total billed charges,3.67,100,,168.192,Fee Schedule,100% of LA custom fee schedule,1586.94,3238,
"Protein Total, Qn, 24-Hr Urine LC",4020233,CDM,301,RC,84156,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,17.08,136.6,,76.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,449.6,fee schedule,136.60% of BCBS custom fee schedule,4.04,110,,25.56,fee schedule,110% of LA custom fee schedule,3.67,100,,25.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.98,38,,52.896,percent of total billed charges,38% of total billed charges,3.67,100,,32,Fee Schedule,100% of LA custom fee schedule,1587.94,3239,
"Protein,Total,Urine LC",4020234,CDM,301,RC,84156,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,17.08,136.6,,449.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,4.04,110,,3.832,fee schedule,110% of LA custom fee schedule,3.67,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.98,38,,115.52,percent of total billed charges,38% of total billed charges,3.67,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1588.94,3240,
"Protein and Creatinine, Random Urine -4020234",4020234,CDM,301,RC,84156,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,17.08,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,4.04,110,,27.352,fee schedule,110% of LA custom fee schedule,3.67,100,,27.352,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.98,38,,24.016,percent of total billed charges,38% of total billed charges,3.67,100,,34.24,Fee Schedule,100% of LA custom fee schedule,1589.94,3241,
"Protein, Body Fluid LC",4020235,CDM,301,RC,84157,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,17.08,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,4.4,110,,2.048,fee schedule,110% of LA custom fee schedule,4,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.5,38,,4.56,percent of total billed charges,38% of total billed charges,4,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1590.94,3242,
"Protein, Total, CSF LC",4020236,CDM,301,RC,84157,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,17.08,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.08,136.6,,44.4,fee schedule,136.60% of BCBS custom fee schedule,4.4,110,,3.064,fee schedule,110% of LA custom fee schedule,4,100,,3.064,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.98,38,,33.44,percent of total billed charges,38% of total billed charges,4,100,,3.84,Fee Schedule,100% of LA custom fee schedule,1591.94,3243,
Protein Electro Serum LC,4020239,CDM,301,RC,84165,HCPCS,OUTPATIENT,,,108,64.8,,91.8,85,,73.44,Percent of total billed charges,85% of total billed charges,50.06,136.6,,44.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.06,136.6,,34.8,fee schedule,136.60% of BCBS custom fee schedule,11.81,110,,1.28,fee schedule,110% of LA custom fee schedule,10.74,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.04,38,,83.6,percent of total billed charges,38% of total billed charges,10.74,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1592.94,3244,
84165 Protein; electrophoretic fractionation and quantitatio,4020239,CDM,301,RC,84165,HCPCS,OUTPATIENT,,,108,64.8,,91.8,85,,73.44,Percent of total billed charges,85% of total billed charges,50.06,136.6,,34.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.06,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,11.81,110,,1.792,fee schedule,110% of LA custom fee schedule,10.74,100,,1.792,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.04,38,,105.792,percent of total billed charges,38% of total billed charges,10.74,100,,2.24,Fee Schedule,100% of LA custom fee schedule,1593.94,3245,
Proinsulin LC,4020240,CDM,301,RC,84206,HCPCS,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,83.05,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,83.05,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,96.056,fee schedule,110% of LA custom fee schedule,14.15,100,,96.056,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.4,38,,16.112,percent of total billed charges,38% of total billed charges,14.15,100,,120.256,Fee Schedule,100% of LA custom fee schedule,1594.94,3246,
Vitamin B6 LC,4020241,CDM,301,RC,84207,HCPCS,OUTPATIENT,,,192,115.2,,163.2,85,,130.56,Percent of total billed charges,85% of total billed charges,65.9,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,65.9,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,18.94,110,,1.024,fee schedule,110% of LA custom fee schedule,17.22,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,72.96,38,,78.432,percent of total billed charges,38% of total billed charges,17.22,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1595.94,3247,
"Renin Activity, Plasma LC",4020243,CDM,301,RC,84244,HCPCS,OUTPATIENT,,,124.6,74.76,,105.91,85,,84.728,Percent of total billed charges,85% of total billed charges,102.55,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,102.55,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,24.19,110,,16.224,fee schedule,110% of LA custom fee schedule,21.99,100,,16.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,47.35,38,,31.616,percent of total billed charges,38% of total billed charges,21.99,100,,20.312,Fee Schedule,100% of LA custom fee schedule,1596.94,3248,
Sex Hormone Binding Globulin LC,4020244,CDM,301,RC,84270,HCPCS,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,101.32,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,101.32,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,6.86,110,,11.504,fee schedule,110% of LA custom fee schedule,6.24,100,,11.504,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.8,38,,38.912,percent of total billed charges,38% of total billed charges,6.24,100,,14.4,Fee Schedule,100% of LA custom fee schedule,1597.94,3249,
SODIUM;SERUM,4020246,CDM,301,RC,84295,HCPCS,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,22.43,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.43,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,5.29,110,,55.72,fee schedule,110% of LA custom fee schedule,4.81,100,,55.72,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.06,38,,64.144,percent of total billed charges,38% of total billed charges,4.81,100,,69.76,Fee Schedule,100% of LA custom fee schedule,1598.94,3250,
"Sodium, Urine LC",4020247,CDM,301,RC,84300,HCPCS,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,22.66,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.66,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,5.57,110,,29.648,fee schedule,110% of LA custom fee schedule,5.06,100,,29.648,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.64,38,,7.6,percent of total billed charges,38% of total billed charges,5.06,100,,37.12,Fee Schedule,100% of LA custom fee schedule,1599.94,3251,
IGF-1 LC,4020249,CDM,301,RC,84305,HCPCS,OUTPATIENT,,,236,141.6,,200.6,85,,160.48,Percent of total billed charges,85% of total billed charges,91.54,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.54,136.6,,8.44,fee schedule,136.60% of BCBS custom fee schedule,23.39,110,,2.048,fee schedule,110% of LA custom fee schedule,21.26,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,89.68,38,,441.712,percent of total billed charges,38% of total billed charges,21.26,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1600.94,3252,
CLINITEST,4020250,CDM,301,RC,84376,HCPCS,OUTPATIENT,,,31,18.6,,26.35,85,,21.08,Percent of total billed charges,85% of total billed charges,25.65,136.6,,8.44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.65,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,6.05,110,,46.008,fee schedule,110% of LA custom fee schedule,5.5,100,,46.008,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.78,38,,31.92,percent of total billed charges,38% of total billed charges,5.5,100,,57.6,Fee Schedule,100% of LA custom fee schedule,1601.94,3253,
"GlycoMark(R)(1,5 AG) (Glucose, Dialysate) LC",4020251,CDM,301,RC,84378,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,37.76,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,37.76,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,12.38,110,,17.128,fee schedule,110% of LA custom fee schedule,11.25,100,,17.128,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.9,38,,24.928,percent of total billed charges,38% of total billed charges,11.25,100,,21.44,Fee Schedule,100% of LA custom fee schedule,1602.94,3254,
"Testosterone, Free, Direct LC",4020252,CDM,301,RC,84402,HCPCS,OUTPATIENT,,,144.28,86.568,,122.64,85,,98.112,Percent of total billed charges,85% of total billed charges,118.69,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,118.69,136.6,,69.2,fee schedule,136.60% of BCBS custom fee schedule,28.02,110,,19.424,fee schedule,110% of LA custom fee schedule,25.47,100,,19.424,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,54.83,38,,29.792,percent of total billed charges,38% of total billed charges,25.47,100,,24.32,Fee Schedule,100% of LA custom fee schedule,1603.94,3255,
"Testosterone, Serum LC",4020253,CDM,301,RC,84403,HCPCS,OUTPATIENT,,,146.28,87.768,,124.34,85,,99.472,Percent of total billed charges,85% of total billed charges,120.41,136.6,,69.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,120.41,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,28.39,110,,28.12,fee schedule,110% of LA custom fee schedule,25.81,100,,28.12,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,55.59,38,,29.792,percent of total billed charges,38% of total billed charges,25.81,100,,35.2,Fee Schedule,100% of LA custom fee schedule,1604.94,3256,
Vitamin B1 (Thiamine) Whl Blood LC,4020254,CDM,301,RC,84425,HCPCS,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,98.99,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.99,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,23.35,110,,23.008,fee schedule,110% of LA custom fee schedule,21.23,100,,23.008,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,45.6,38,,53.2,percent of total billed charges,38% of total billed charges,21.23,100,,28.8,Fee Schedule,100% of LA custom fee schedule,1605.94,3257,
Thyroglobulin Reflex Profile LC,4020255,CDM,309,RC,84432,HCPCS,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,74.87,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.87,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,17.67,110,,35.784,fee schedule,110% of LA custom fee schedule,16.06,100,,35.784,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.8,38,,22.8,percent of total billed charges,38% of total billed charges,16.06,100,,44.8,Fee Schedule,100% of LA custom fee schedule,1606.94,3258,
Thyroxine (T4) LC,4020256,CDM,301,RC,84436,HCPCS,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,22.55,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.55,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,6.45,110,,27.352,fee schedule,110% of LA custom fee schedule,5.86,100,,27.352,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.26,38,,34.048,percent of total billed charges,38% of total billed charges,5.86,100,,34.24,Fee Schedule,100% of LA custom fee schedule,1607.94,3259,
FREE T4,4020257,CDM,301,RC,84439,HCPCS,OUTPATIENT,,,51.08,30.648,,43.42,85,,34.736,Percent of total billed charges,85% of total billed charges,42.03,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,42.03,136.6,,778,fee schedule,136.60% of BCBS custom fee schedule,9.92,110,,12.016,fee schedule,110% of LA custom fee schedule,9.02,100,,12.016,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.41,38,,76,percent of total billed charges,38% of total billed charges,9.02,100,,15.04,Fee Schedule,100% of LA custom fee schedule,1608.94,3260,
Thyroxine Free,4020257,CDM,301,RC,84439,HCPCS,OUTPATIENT,,,51.08,30.648,,43.42,85,,34.736,Percent of total billed charges,85% of total billed charges,42.03,136.6,,778,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,42.03,136.6,,778,fee schedule,136.60% of BCBS custom fee schedule,9.92,110,,9.712,fee schedule,110% of LA custom fee schedule,9.02,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.41,38,,85.12,percent of total billed charges,38% of total billed charges,9.02,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1609.94,3261,
THYROID STIM HORMONE,4020258,CDM,301,RC,84443,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,78.33,136.6,,778,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.33,136.6,,920,fee schedule,136.60% of BCBS custom fee schedule,18.48,110,,42.944,fee schedule,110% of LA custom fee schedule,16.8,100,,42.944,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.1,38,,45.6,percent of total billed charges,38% of total billed charges,16.8,100,,53.76,Fee Schedule,100% of LA custom fee schedule,1610.94,3262,
TSH,4020258,CDM,301,RC,84443,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,78.33,136.6,,920,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.33,136.6,,74,fee schedule,136.60% of BCBS custom fee schedule,18.48,110,,4.344,fee schedule,110% of LA custom fee schedule,16.8,100,,4.344,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.1,38,,5.168,percent of total billed charges,38% of total billed charges,16.8,100,,5.44,Fee Schedule,100% of LA custom fee schedule,1611.94,3263,
Thyroid Stim Immunoglobulin LC,4020259,CDM,309,RC,84445,HCPCS,OUTPATIENT,,,256,153.6,,217.6,85,,174.08,Percent of total billed charges,85% of total billed charges,85.78,136.6,,74,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,85.78,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,24.67,110,,31.696,fee schedule,110% of LA custom fee schedule,22.43,100,,31.696,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,97.28,38,,59.28,percent of total billed charges,38% of total billed charges,22.43,100,,39.68,Fee Schedule,100% of LA custom fee schedule,1612.94,3264,
"Vitamin E, Serum LC",4020260,CDM,301,RC,84446,HCPCS,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,66.11,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.11,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,15.6,110,,0.512,fee schedule,110% of LA custom fee schedule,14.18,100,,0.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.4,38,,74.784,percent of total billed charges,38% of total billed charges,14.18,100,,0.64,Fee Schedule,100% of LA custom fee schedule,1613.94,3265,
84446 Vitamin A and E LC,4020260,CDM,301,RC,84446,HCPCS,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,66.11,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.11,136.6,,50.8,fee schedule,136.60% of BCBS custom fee schedule,15.6,110,,2.56,fee schedule,110% of LA custom fee schedule,14.18,100,,2.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.4,38,,52.896,percent of total billed charges,38% of total billed charges,14.18,100,,3.2,Fee Schedule,100% of LA custom fee schedule,1614.94,3266,
Thyroxine Binding Globulin LC,4020261,CDM,301,RC,84442,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,61.17,136.6,,50.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.17,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,16.26,110,,92.016,fee schedule,110% of LA custom fee schedule,14.78,100,,92.016,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.5,38,,20.368,percent of total billed charges,38% of total billed charges,14.78,100,,115.2,Fee Schedule,100% of LA custom fee schedule,1615.94,3267,
TRANSFERASE; ASPARTATE,4020262,CDM,301,RC,84450,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,24.1,136.6,,4.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.1,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,18.144,fee schedule,110% of LA custom fee schedule,5.18,100,,18.144,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,29.488,percent of total billed charges,38% of total billed charges,5.18,100,,22.72,Fee Schedule,100% of LA custom fee schedule,1616.94,3268,
Transferase; aspartate amino (AST) (SGOT),4020262,CDM,301,RC,84450,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,24.1,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.1,136.6,,196,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,7.672,fee schedule,110% of LA custom fee schedule,5.18,100,,7.672,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,28.88,percent of total billed charges,38% of total billed charges,5.18,100,,9.6,Fee Schedule,100% of LA custom fee schedule,1617.94,3269,
TRANSFERASE ALANINE AMINO  84460,4020263,CDM,309,RC,84460,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.71,136.6,,196,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.71,136.6,,212,fee schedule,136.60% of BCBS custom fee schedule,5.83,110,,2.304,fee schedule,110% of LA custom fee schedule,5.3,100,,2.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,26.752,percent of total billed charges,38% of total billed charges,5.3,100,,2.88,Fee Schedule,100% of LA custom fee schedule,1618.94,3270,
Transferase; alanine amino (ALT) (SGPT),4020263,CDM,301,RC,84460,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.71,136.6,,212,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.71,136.6,,216,fee schedule,136.60% of BCBS custom fee schedule,5.83,110,,408.96,fee schedule,110% of LA custom fee schedule,5.3,100,,408.96,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,39.52,percent of total billed charges,38% of total billed charges,5.3,100,,512,Fee Schedule,100% of LA custom fee schedule,1619.94,3271,
TRANSFERRIN,4020264,CDM,301,RC,84466,HCPCS,OUTPATIENT,,,72,43.2,,61.2,85,,48.96,Percent of total billed charges,85% of total billed charges,59.53,136.6,,216,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,59.53,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,14.04,110,,11.76,fee schedule,110% of LA custom fee schedule,12.76,100,,11.76,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.36,38,,65.664,percent of total billed charges,38% of total billed charges,12.76,100,,14.72,Fee Schedule,100% of LA custom fee schedule,1620.94,3272,
ASSAY OF TRIGLYCERIDES  84478,4020265,CDM,301,RC,84478,HCPCS,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,26.83,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.83,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,6.31,110,,46.96,fee schedule,110% of LA custom fee schedule,5.74,100,,1150.2,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.2,38,,121.296,percent of total billed charges,38% of total billed charges,5.74,100,,42.688,Fee Schedule,100% of LA custom fee schedule,1621.94,3273,
Triglycerides,4020265,CDM,301,RC,84478,HCPCS,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,26.83,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.83,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,6.31,110,,389.792,fee schedule,110% of LA custom fee schedule,5.74,100,,389.792,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.2,38,,135.28,percent of total billed charges,38% of total billed charges,5.74,100,,488,Fee Schedule,100% of LA custom fee schedule,1622.94,3274,
T3 Uptake LC,4020266,CDM,301,RC,84479,HCPCS,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,21.69,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.69,136.6,,26,fee schedule,136.60% of BCBS custom fee schedule,6.26,110,,2.528,fee schedule,110% of LA custom fee schedule,5.69,100,,1170.648,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.88,38,,17.936,percent of total billed charges,38% of total billed charges,5.69,100,,2.304,Fee Schedule,100% of LA custom fee schedule,1623.94,3275,
Triiodothyronine (T3) LC,4020267,CDM,301,RC,84480,HCPCS,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,29.94,136.6,,26,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.94,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,8.61,110,,3.576,fee schedule,110% of LA custom fee schedule,7.83,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.94,38,,31.008,percent of total billed charges,38% of total billed charges,7.83,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1624.94,3276,
Triiodothyronine Free Serum LC,4020268,CDM,301,RC,84481,HCPCS,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,45.97,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.97,136.6,,208,fee schedule,136.60% of BCBS custom fee schedule,13.22,110,,7.672,fee schedule,110% of LA custom fee schedule,12.02,100,,7.672,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.8,38,,119.168,percent of total billed charges,38% of total billed charges,12.02,100,,9.6,Fee Schedule,100% of LA custom fee schedule,1625.94,3277,
Reverse T3 LC,4020269,CDM,301,RC,84482,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,21.69,136.6,,208,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.69,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,6.26,110,,88.44,fee schedule,110% of LA custom fee schedule,5.69,100,,88.44,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,8.816,percent of total billed charges,38% of total billed charges,5.69,100,,110.72,Fee Schedule,100% of LA custom fee schedule,1626.94,3278,
TROPONIN,4020270,CDM,301,RC,84484,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,45.88,136.6,,8.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.88,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,13.72,110,,15.12,fee schedule,110% of LA custom fee schedule,12.47,100,,15.12,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,21.28,38,,25.232,percent of total billed charges,38% of total billed charges,12.47,100,,18.936,Fee Schedule,100% of LA custom fee schedule,1627.94,3279,
Troponin I 1,4020270,CDM,301,RC,84484,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,45.88,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.88,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,13.72,110,,53.68,fee schedule,110% of LA custom fee schedule,12.47,100,,53.68,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,21.28,38,,40.736,percent of total billed charges,38% of total billed charges,12.47,100,,67.2,Fee Schedule,100% of LA custom fee schedule,1628.94,3280,
Troponin I High Sensitivity,4020270,CDM,300,RC,84484,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,45.88,136.6,,5.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.88,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,13.72,110,,4.344,fee schedule,110% of LA custom fee schedule,12.47,100,,4.344,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,21.28,38,,24.928,percent of total billed charges,38% of total billed charges,12.47,100,,5.44,Fee Schedule,100% of LA custom fee schedule,1629.94,3281,
UREA NITRO;QUAN,4020271,CDM,301,RC,84520,HCPCS,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,18.37,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.37,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,4.35,110,,9.712,fee schedule,110% of LA custom fee schedule,3.95,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.36,38,,37.088,percent of total billed charges,38% of total billed charges,3.95,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1630.94,3282,
URIC ACID BLOOD,4020272,CDM,301,RC,84550,HCPCS,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,21.06,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.06,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,4.97,110,,33.48,fee schedule,110% of LA custom fee schedule,4.52,100,,33.48,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,10.26,38,,34.96,percent of total billed charges,38% of total billed charges,4.52,100,,41.92,Fee Schedule,100% of LA custom fee schedule,1631.94,3283,
"Vanillylmandelic Acid, 24-Hr U LC",4020273,CDM,301,RC,84585,HCPCS,OUTPATIENT,,,106,63.6,,90.1,85,,72.08,Percent of total billed charges,85% of total billed charges,72.28,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,72.28,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,17.05,110,,67.48,fee schedule,110% of LA custom fee schedule,15.5,100,,67.48,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,40.28,38,,1580.8,percent of total billed charges,38% of total billed charges,15.5,100,,84.48,Fee Schedule,100% of LA custom fee schedule,1632.94,3284,
"Vitamin A, Serum LC",4020274,CDM,301,RC,84590,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.07,136.6,,1.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.07,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,12.77,110,,17.384,fee schedule,110% of LA custom fee schedule,11.61,100,,17.384,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,49.248,percent of total billed charges,38% of total billed charges,11.61,100,,21.76,Fee Schedule,100% of LA custom fee schedule,1633.94,3285,
Vitamin A and E LC,4020274,CDM,301,RC,84590,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.07,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.07,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,12.77,110,,71.056,fee schedule,110% of LA custom fee schedule,11.61,100,,71.056,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,40.128,percent of total billed charges,38% of total billed charges,11.61,100,,88.96,Fee Schedule,100% of LA custom fee schedule,1634.94,3286,
ADH LC,4020275,CDM,301,RC,84588,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,158.26,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,158.26,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,30.03,110,,5.904,fee schedule,110% of LA custom fee schedule,27.3,100,,1232.76,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,84.208,percent of total billed charges,38% of total billed charges,27.3,100,,5.368,Fee Schedule,100% of LA custom fee schedule,1635.94,3287,
"Zinc, Plasma or Serum LC",4020276,CDM,300,RC,84630,HCPCS,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,53.08,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.08,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,12.53,110,,1.792,fee schedule,110% of LA custom fee schedule,11.39,100,,1.792,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.58,38,,26.448,percent of total billed charges,38% of total billed charges,11.39,100,,2.24,Fee Schedule,100% of LA custom fee schedule,1636.94,3288,
"Zinc, Whole Blood LC",4020276,CDM,300,RC,84630,HCPCS,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,53.08,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.08,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,12.53,110,,2.048,fee schedule,110% of LA custom fee schedule,11.39,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.58,38,,21.28,percent of total billed charges,38% of total billed charges,11.39,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1637.94,3289,
Vitamin K1 LC,4020277,CDM,301,RC,84597,HCPCS,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,63.9,136.6,,10,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.9,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,11.28,110,,14.824,fee schedule,110% of LA custom fee schedule,10.25,100,,14.824,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.96,38,,29.792,percent of total billed charges,38% of total billed charges,10.25,100,,18.56,Fee Schedule,100% of LA custom fee schedule,1638.94,3290,
"C-Peptide, Serum LC",4020278,CDM,301,RC,84681,HCPCS,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,97,136.6,,45.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,97,136.6,,111.2,fee schedule,136.60% of BCBS custom fee schedule,37.7,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,37.7,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.84,38,,72.656,percent of total billed charges,38% of total billed charges,47.2,40,,16.64,percent of total billed charges,40% of total billed charges,1639.94,3291,
BETA HCG SUBUNIT,4020279,CDM,301,RC,84702,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,70.16,136.6,,111.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.16,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,16.56,110,,2.328,fee schedule,110% of LA custom fee schedule,15.05,100,,2.328,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.3,38,,148.048,percent of total billed charges,38% of total billed charges,15.05,100,,2.912,Fee Schedule,100% of LA custom fee schedule,1640.94,3292,
"hCG,Beta Subunit, Qnt, Serum LC",4020280,CDM,301,RC,84702,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,70.16,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.16,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,16.56,110,,3.064,fee schedule,110% of LA custom fee schedule,15.05,100,,3.064,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.3,38,,30.4,percent of total billed charges,38% of total billed charges,15.05,100,,3.84,Fee Schedule,100% of LA custom fee schedule,1641.94,3293,
hCG Qualitative LC,4020281,CDM,301,RC,84703,HCPCS,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,35.01,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.01,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,8.27,110,,3.064,fee schedule,110% of LA custom fee schedule,7.52,100,,3.064,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.34,38,,30.4,percent of total billed charges,38% of total billed charges,7.52,100,,3.84,Fee Schedule,100% of LA custom fee schedule,1642.94,3294,
BLD CT; OTHER THAN SPU,4020282,CDM,305,RC,85014,HCPCS,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,11.05,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.05,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,2.61,110,,11.248,fee schedule,110% of LA custom fee schedule,2.37,100,,11.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.94,38,,30.4,percent of total billed charges,38% of total billed charges,2.37,100,,14.08,Fee Schedule,100% of LA custom fee schedule,1643.94,3295,
Hematocrit,4020282,CDM,305,RC,85014,HCPCS,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,11.05,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.05,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,2.61,110,,10.992,fee schedule,110% of LA custom fee schedule,2.37,100,,10.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.94,38,,30.4,percent of total billed charges,38% of total billed charges,2.37,100,,13.76,Fee Schedule,100% of LA custom fee schedule,1644.94,3296,
BLD CT; HGB,4020283,CDM,305,RC,85018,HCPCS,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,11.05,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.05,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,2.61,110,,3.832,fee schedule,110% of LA custom fee schedule,2.37,100,,3.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.94,38,,10.944,percent of total billed charges,38% of total billed charges,2.37,100,,4.8,Fee Schedule,100% of LA custom fee schedule,1645.94,3297,
Hemoglobin POC,4020283,CDM,300,RC,85018,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,11.05,136.6,,5.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.05,136.6,,39.6,fee schedule,136.60% of BCBS custom fee schedule,2.61,110,,9.712,fee schedule,110% of LA custom fee schedule,2.37,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.7,38,,27.664,percent of total billed charges,38% of total billed charges,2.37,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1646.94,3298,
Hemoglobin,4020283,CDM,305,RC,85018,HCPCS,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,11.05,136.6,,39.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.05,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,2.61,110,,29.392,fee schedule,110% of LA custom fee schedule,2.37,100,,29.392,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.94,38,,28.272,percent of total billed charges,38% of total billed charges,2.37,100,,36.8,Fee Schedule,100% of LA custom fee schedule,1647.94,3299,
COMPLETE CBC W/AUTO DIFF WBC,4020285,CDM,305,RC,85025,HCPCS,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,36.24,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.24,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,8.55,110,,26.584,fee schedule,110% of LA custom fee schedule,7.77,100,,26.584,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.72,38,,28.272,percent of total billed charges,38% of total billed charges,7.77,100,,33.28,Fee Schedule,100% of LA custom fee schedule,1648.94,3300,
COMPLETE CBC W/AUTO DIFF WBC BCE Charge,4020285,CDM,305,RC,85025,HCPCS,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,36.24,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.24,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,8.55,110,,5.624,fee schedule,110% of LA custom fee schedule,7.77,100,,5.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.72,38,,28.272,percent of total billed charges,38% of total billed charges,7.77,100,,7.04,Fee Schedule,100% of LA custom fee schedule,1649.94,3301,
CBC w/Diff Standard,4020287,CDM,305,RC,85025,HCPCS,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,36.24,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.24,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,8.55,110,,258.16,fee schedule,110% of LA custom fee schedule,7.77,100,,258.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.38,38,,20.672,percent of total billed charges,38% of total billed charges,7.77,100,,323.2,Fee Schedule,100% of LA custom fee schedule,1650.94,3302,
COMPLETE CBC AUTOMATED,4020287,CDM,305,RC,85025,HCPCS,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,36.24,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.24,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,8.55,110,,1.024,fee schedule,110% of LA custom fee schedule,7.77,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.38,38,,20.672,percent of total billed charges,38% of total billed charges,7.77,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1651.94,3303,
CBC WITH NO DIFF,4020288,CDM,305,RC,85027,HCPCS,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,30.17,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.17,136.6,,42,fee schedule,136.60% of BCBS custom fee schedule,7.12,110,,3.192,fee schedule,110% of LA custom fee schedule,6.47,100,,3.192,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.44,38,,20.672,percent of total billed charges,38% of total billed charges,6.47,100,,4,Fee Schedule,100% of LA custom fee schedule,1652.94,3304,
Reticulocyte Count,4020290,CDM,300,RC,85045,HCPCS,OUTPATIENT,,,22.68,13.608,,19.28,85,,15.424,Percent of total billed charges,85% of total billed charges,18.66,136.6,,42,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.66,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,4.39,110,,5.88,fee schedule,110% of LA custom fee schedule,3.99,100,,5.88,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.62,38,,57.76,percent of total billed charges,38% of total billed charges,3.99,100,,7.36,Fee Schedule,100% of LA custom fee schedule,1653.94,3305,
Reticulocyte Count LC,4020290,CDM,300,RC,85045,HCPCS,OUTPATIENT,,,22.68,13.608,,19.28,85,,15.424,Percent of total billed charges,85% of total billed charges,18.66,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.66,136.6,,9.6,fee schedule,136.60% of BCBS custom fee schedule,4.39,110,,3.192,fee schedule,110% of LA custom fee schedule,3.99,100,,3.192,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.62,38,,10.032,percent of total billed charges,38% of total billed charges,3.99,100,,4,Fee Schedule,100% of LA custom fee schedule,1654.94,3306,
BLD CT;WHITE BLD CELL,4020291,CDM,305,RC,85048,HCPCS,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,11.83,136.6,,9.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.83,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,2.79,110,,48.312,fee schedule,110% of LA custom fee schedule,2.54,100,,48.312,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,5.32,38,,45.6,percent of total billed charges,38% of total billed charges,2.54,100,,60.48,Fee Schedule,100% of LA custom fee schedule,1655.94,3307,
PLATELET; AUTOMATED CT,4020293,CDM,305,RC,85049,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,19.12,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.12,136.6,,156,fee schedule,136.60% of BCBS custom fee schedule,4.93,110,,21.728,fee schedule,110% of LA custom fee schedule,4.48,100,,21.728,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,41.496,percent of total billed charges,38% of total billed charges,4.48,100,,27.2,Fee Schedule,100% of LA custom fee schedule,1656.94,3308,
Factor VIII Activity LC,4020299,CDM,305,RC,85246,HCPCS,OUTPATIENT,,,156,93.6,,132.6,85,,106.08,Percent of total billed charges,85% of total billed charges,106.99,136.6,,156,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,25.23,110,,4.088,fee schedule,110% of LA custom fee schedule,22.94,100,,4.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,59.28,38,,41.496,percent of total billed charges,38% of total billed charges,22.94,100,,5.12,Fee Schedule,100% of LA custom fee schedule,1657.94,3309,
Protein C Antigen LC,4020303,CDM,305,RC,85302,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,56.06,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.06,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,13.21,110,,228.76,fee schedule,110% of LA custom fee schedule,12.01,100,,228.76,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,41.496,percent of total billed charges,38% of total billed charges,12.01,100,,286.4,Fee Schedule,100% of LA custom fee schedule,1658.94,3310,
D-DIMER,4020307,CDM,305,RC,85379,HCPCS,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,47.45,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,47.45,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,11.2,110,,90.992,fee schedule,110% of LA custom fee schedule,10.18,100,,90.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.4,38,,41.496,percent of total billed charges,38% of total billed charges,10.18,100,,113.92,Fee Schedule,100% of LA custom fee schedule,1659.94,3311,
Fibrinogen Activity LC,4020308,CDM,305,RC,85384,HCPCS,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,39.6,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.6,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,10.69,110,,90.992,fee schedule,110% of LA custom fee schedule,9.72,100,,90.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.24,38,,41.496,percent of total billed charges,38% of total billed charges,9.72,100,,113.92,Fee Schedule,100% of LA custom fee schedule,1660.94,3312,
Platelet Function LC,4020309,CDM,305,RC,85576,HCPCS,OUTPATIENT,,,147,88.2,,124.95,85,,99.96,Percent of total billed charges,85% of total billed charges,100.13,136.6,,7.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,100.13,136.6,,27.6,fee schedule,136.60% of BCBS custom fee schedule,17.99,110,,90.992,fee schedule,110% of LA custom fee schedule,16.35,100,,90.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,55.86,38,,41.496,percent of total billed charges,38% of total billed charges,16.35,100,,113.92,Fee Schedule,100% of LA custom fee schedule,1661.94,3313,
PROTHROMBIN TIME,4020312,CDM,305,RC,85610,HCPCS,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,18.32,136.6,,27.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.32,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,4.72,110,,90.992,fee schedule,110% of LA custom fee schedule,4.29,100,,90.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.36,38,,63.84,percent of total billed charges,38% of total billed charges,4.29,100,,113.92,Fee Schedule,100% of LA custom fee schedule,1662.94,3314,
Prothrombin Time,4020312,CDM,305,RC,85610,HCPCS,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,18.32,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.32,136.6,,88,fee schedule,136.60% of BCBS custom fee schedule,4.72,110,,12.272,fee schedule,110% of LA custom fee schedule,4.29,100,,12.272,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.36,38,,60.8,percent of total billed charges,38% of total billed charges,4.29,100,,15.36,Fee Schedule,100% of LA custom fee schedule,1663.94,3315,
PT/INR,4020312,CDM,305,RC,85610,HCPCS,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,18.32,136.6,,88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.32,136.6,,137.6,fee schedule,136.60% of BCBS custom fee schedule,4.72,110,,12.272,fee schedule,110% of LA custom fee schedule,4.29,100,,12.272,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,8.36,38,,281.504,percent of total billed charges,38% of total billed charges,4.29,100,,15.36,Fee Schedule,100% of LA custom fee schedule,1664.94,3316,
SED RATE ERYTHROCYTE N,4020314,CDM,305,RC,85651,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,16.54,136.6,,137.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.54,136.6,,144,fee schedule,136.60% of BCBS custom fee schedule,4.7,110,,12.272,fee schedule,110% of LA custom fee schedule,4.27,100,,12.272,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.6,38,,34.96,percent of total billed charges,38% of total billed charges,4.27,100,,15.36,Fee Schedule,100% of LA custom fee schedule,1665.94,3317,
PTT; PLASMA/WHOLE BLD,4020319,CDM,305,RC,85730,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,27.96,136.6,,144,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.96,136.6,,227.2,fee schedule,136.60% of BCBS custom fee schedule,6.61,110,,1.28,fee schedule,110% of LA custom fee schedule,6.01,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,7.6,percent of total billed charges,38% of total billed charges,6.01,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1666.94,3318,
Partial Thromboplastin Time,4020319,CDM,305,RC,85370,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,47.65,136.6,,227.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,47.65,136.6,,340.8,fee schedule,136.60% of BCBS custom fee schedule,13.28,110,,4.088,fee schedule,110% of LA custom fee schedule,12.07,100,,4.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,7.6,percent of total billed charges,38% of total billed charges,12.07,100,,5.12,Fee Schedule,100% of LA custom fee schedule,1667.94,3319,
F013-IgE Peanut LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,340.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,454.4,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,14.312,fee schedule,110% of LA custom fee schedule,5.22,100,,14.312,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,45.6,percent of total billed charges,38% of total billed charges,5.22,100,,17.92,Fee Schedule,100% of LA custom fee schedule,1668.94,3320,
F014-IgE Soybean LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,454.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,681.6,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,45.6,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1669.94,3321,
F004-IgE Wheat LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,681.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,681.6,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,45.6,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1670.94,3322,
F002-IgE Milk (Cow) LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,681.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,51.072,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1671.94,3323,
F001-IgE Wheat LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,172,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,12.16,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1672.94,3324,
D001-IgE D pteronyssinus LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,14.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,1.408,fee schedule,110% of LA custom fee schedule,5.22,100,,1234.552,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,212.8,percent of total billed charges,38% of total billed charges,5.22,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1673.94,3325,
E001-IgE Cat Dander LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,11.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,0.256,fee schedule,110% of LA custom fee schedule,5.22,100,,0.256,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,46.816,percent of total billed charges,38% of total billed charges,5.22,100,,0.32,Fee Schedule,100% of LA custom fee schedule,1674.94,3326,
E005-IgE Dog Dander LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,116,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,15.2,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1675.94,3327,
"I206-IgE Cockroach, American LC",4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,116,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,15.2,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1676.94,3328,
F075-IgE Egg (Yolk) LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,141.36,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1677.94,3329,
C002-IgE Penicillin V LC,4020322,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,19.936,fee schedule,110% of LA custom fee schedule,5.22,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,152,percent of total billed charges,38% of total billed charges,5.22,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1678.94,3330,
Heparin Induced Platelet Antibody LC,4020325,CDM,302,RC,86022,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,85.63,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,85.63,136.6,,20.4,fee schedule,136.60% of BCBS custom fee schedule,20.21,110,,19.936,fee schedule,110% of LA custom fee schedule,18.37,100,,19.936,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,47.5,38,,141.36,percent of total billed charges,38% of total billed charges,18.37,100,,24.96,Fee Schedule,100% of LA custom fee schedule,1679.94,3331,
Antinuclear Antibodies Direct LC,4020326,CDM,302,RC,86038,HCPCS,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,56.36,136.6,,20.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.36,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,13.3,110,,16.104,fee schedule,110% of LA custom fee schedule,12.09,100,,16.104,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,46.36,38,,3040,percent of total billed charges,38% of total billed charges,12.09,100,,20.16,Fee Schedule,100% of LA custom fee schedule,1680.94,3332,
"ANA, IFA Reflex to Multiplex, Qnt LC",4020326,CDM,302,RC,86038,HCPCS,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,56.36,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.36,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,13.3,110,,16.104,fee schedule,110% of LA custom fee schedule,12.09,100,,16.104,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,46.36,38,,141.36,percent of total billed charges,38% of total billed charges,12.09,100,,20.16,Fee Schedule,100% of LA custom fee schedule,1681.94,3333,
"86225 ANA, IFA Reflex to Multiplex, Gnt LC",4020326,CDM,302,RC,86225,HCPCS,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,64.08,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,64.08,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,15.11,110,,16.104,fee schedule,110% of LA custom fee schedule,13.74,100,,16.104,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.72,38,,267.824,percent of total billed charges,38% of total billed charges,13.74,100,,20.16,Fee Schedule,100% of LA custom fee schedule,1682.94,3334,
Antistreptolysin O Ab LC,4020329,CDM,302,RC,86060,HCPCS,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,34.04,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.04,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,8.03,110,,4.6,fee schedule,110% of LA custom fee schedule,7.3,100,,4.6,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.58,38,,883.424,percent of total billed charges,38% of total billed charges,7.3,100,,5.76,Fee Schedule,100% of LA custom fee schedule,1683.94,3335,
C-REATIVE PROTEIN,4020330,CDM,302,RC,86140,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,24.12,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,1.28,fee schedule,110% of LA custom fee schedule,5.18,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,152,percent of total billed charges,38% of total billed charges,5.18,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1684.94,3336,
"C-Reactive Protein, Cardiac LC",4020331,CDM,302,RC,86141,HCPCS,OUTPATIENT,,,73,43.8,,62.05,85,,49.64,Percent of total billed charges,85% of total billed charges,60.38,136.6,,15.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.38,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,14.25,110,,1.28,fee schedule,110% of LA custom fee schedule,12.95,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.74,38,,152,percent of total billed charges,38% of total billed charges,12.95,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1685.94,3337,
Complement C2 LC,4020337,CDM,302,RC,86160,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.99,136.6,,17.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.99,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,13.2,110,,0.256,fee schedule,110% of LA custom fee schedule,12,100,,0.256,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,152,percent of total billed charges,38% of total billed charges,12,100,,0.32,Fee Schedule,100% of LA custom fee schedule,1686.94,3338,
"Complement C3, Serum LC",4020338,CDM,302,RC,86160,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.99,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.99,136.6,,38.4,fee schedule,136.60% of BCBS custom fee schedule,13.2,110,,15.552,fee schedule,110% of LA custom fee schedule,12,100,,15.552,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,152,percent of total billed charges,38% of total billed charges,12,100,,19.464,Fee Schedule,100% of LA custom fee schedule,1687.94,3339,
"Complement C4, Serum LC",4020339,CDM,302,RC,86160,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.99,136.6,,38.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.99,136.6,,35.2,fee schedule,136.60% of BCBS custom fee schedule,13.2,110,,21.472,fee schedule,110% of LA custom fee schedule,12,100,,21.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,242.592,percent of total billed charges,38% of total billed charges,12,100,,26.88,Fee Schedule,100% of LA custom fee schedule,1688.94,3340,
"Complement, Total (CH50) LC",4020341,CDM,302,RC,86162,HCPCS,OUTPATIENT,,,108,64.8,,91.8,85,,73.44,Percent of total billed charges,85% of total billed charges,88.93,136.6,,35.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,88.93,136.6,,232.8,fee schedule,136.60% of BCBS custom fee schedule,22.35,110,,3.576,fee schedule,110% of LA custom fee schedule,20.32,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.04,38,,979.792,percent of total billed charges,38% of total billed charges,20.32,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1689.94,3341,
CCP Antibodies IgG/IgA LC,4020342,CDM,302,RC,86200,HCPCS,OUTPATIENT,,,89,53.4,,75.65,85,,60.52,Percent of total billed charges,85% of total billed charges,50.94,136.6,,232.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.94,136.6,,232.8,fee schedule,136.60% of BCBS custom fee schedule,14.25,110,,30.16,fee schedule,110% of LA custom fee schedule,12.95,100,,30.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.82,38,,392.768,percent of total billed charges,38% of total billed charges,12.95,100,,37.76,Fee Schedule,100% of LA custom fee schedule,1690.94,3342,
Anti-dsDNA Antibodies LC,4020343,CDM,302,RC,86225,HCPCS,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,64.08,136.6,,232.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,64.08,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,15.11,110,,6.352,fee schedule,110% of LA custom fee schedule,13.74,100,,10.4,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.72,38,,289.104,percent of total billed charges,38% of total billed charges,13.74,100,,5.776,Fee Schedule,100% of LA custom fee schedule,1691.94,3343,
Actin (Smooth Muscle) Antibody LC,4020345,CDM,302,RC,86235,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.24,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.24,136.6,,440,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,1.216,fee schedule,110% of LA custom fee schedule,14.15,100,,1.216,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,152,percent of total billed charges,38% of total billed charges,14.15,100,,1.52,Fee Schedule,100% of LA custom fee schedule,1692.94,3344,
"Sjogren's Ab, Anti-SS-A/-SS-B LC",4020347,CDM,301,RC,86235,HCPCS,OUTPATIENT,,,132,79.2,,112.2,85,,89.76,Percent of total billed charges,85% of total billed charges,54.24,136.6,,440,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.24,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,4.088,fee schedule,110% of LA custom fee schedule,14.15,100,,4.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,50.16,38,,304,percent of total billed charges,38% of total billed charges,14.15,100,,5.12,Fee Schedule,100% of LA custom fee schedule,1693.94,3345,
Endomysial Antibody IgA LC,4020348,CDM,302,RC,86255,HCPCS,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,52.92,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.92,136.6,,72.4,fee schedule,136.60% of BCBS custom fee schedule,13.26,110,,3.376,fee schedule,110% of LA custom fee schedule,12.05,100,,102.24,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,46.36,38,,196.384,percent of total billed charges,38% of total billed charges,12.05,100,,3.064,Fee Schedule,100% of LA custom fee schedule,1694.94,3346,
CA 27.29 LC,4020351,CDM,302,RC,86300,HCPCS,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,97,136.6,,72.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,97,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,22.89,110,,7.416,fee schedule,110% of LA custom fee schedule,20.81,100,,7.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,44.84,38,,230.128,percent of total billed charges,38% of total billed charges,20.81,100,,9.28,Fee Schedule,100% of LA custom fee schedule,1695.94,3347,
Carbohydrate Antigen 19-9 LC,4020353,CDM,302,RC,86301,HCPCS,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,97,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,97,136.6,,96,fee schedule,136.60% of BCBS custom fee schedule,22.89,110,,3.656,fee schedule,110% of LA custom fee schedule,20.81,100,,102.24,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,44.84,38,,436.544,percent of total billed charges,38% of total billed charges,20.81,100,,3.32,Fee Schedule,100% of LA custom fee schedule,1696.94,3348,
Cancer Antigen (CA) 125 LC,4020354,CDM,302,RC,86304,HCPCS,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,97,136.6,,96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,97,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,22.89,110,,2.048,fee schedule,110% of LA custom fee schedule,20.81,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,44.84,38,,244.416,percent of total billed charges,38% of total billed charges,20.81,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1697.94,3349,
Heterophile Antibody Screen,4020355,CDM,302,RC,86308,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,24.12,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,88,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,10.48,fee schedule,110% of LA custom fee schedule,5.18,100,,10.48,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,245.024,percent of total billed charges,38% of total billed charges,5.18,100,,13.12,Fee Schedule,100% of LA custom fee schedule,1698.94,3350,
Monospot POC,4020355,CDM,300,RC,86308,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,24.12,136.6,,88,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.12,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,5.7,110,,6.224,fee schedule,110% of LA custom fee schedule,5.18,100,,102.24,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,152,percent of total billed charges,38% of total billed charges,5.18,100,,5.656,Fee Schedule,100% of LA custom fee schedule,1699.94,3351,
Pneumococcal Immunity 14 type LC,4020359,CDM,302,RC,86317,HCPCS,OUTPATIENT,,,1189.44,713.664,,1011.02,85,,808.816,Percent of total billed charges,85% of total billed charges,69.91,136.6,,7.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.91,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,16.49,110,,7.336,fee schedule,110% of LA custom fee schedule,14.99,100,,7.336,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,451.99,38,,1184.688,percent of total billed charges,38% of total billed charges,14.99,100,,9.184,Fee Schedule,100% of LA custom fee schedule,1700.94,3352,
Insulin Antibodies LC,4020364,CDM,302,RC,86337,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,48.75,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,48.75,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,10.86,110,,4.496,fee schedule,110% of LA custom fee schedule,9.87,100,,102.752,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.7,38,,279.984,percent of total billed charges,38% of total billed charges,9.87,100,,4.088,Fee Schedule,100% of LA custom fee schedule,1701.94,3353,
Helper T-Lymph-CD4 LC,4020369,CDM,302,RC,86361,HCPCS,OUTPATIENT,,,138,82.8,,117.3,85,,93.84,Percent of total billed charges,85% of total billed charges,93.87,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,93.87,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,29.46,110,,3.576,fee schedule,110% of LA custom fee schedule,26.78,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,52.44,38,,336.224,percent of total billed charges,38% of total billed charges,26.78,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1702.94,3354,
Thyroid Peroxidase (TPO) Ab LC,4020371,CDM,302,RC,86376,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,67.84,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,67.84,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,16.01,110,,17.128,fee schedule,110% of LA custom fee schedule,14.55,100,,17.128,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,910.784,percent of total billed charges,38% of total billed charges,14.55,100,,21.44,Fee Schedule,100% of LA custom fee schedule,1703.94,3355,
Rheumatoid Arthritis Factor LC,4020372,CDM,302,RC,86431,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,26.47,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.47,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,6.24,110,,1.672,fee schedule,110% of LA custom fee schedule,5.67,100,,103.264,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.16,38,,88.464,percent of total billed charges,38% of total billed charges,5.67,100,,1.52,Fee Schedule,100% of LA custom fee schedule,1704.94,3356,
QuantiFERON TB Gold (In Tube) LC,4020373,CDM,302,RC,86480,HCPCS,OUTPATIENT,,,423,253.8,,359.55,85,,287.64,Percent of total billed charges,85% of total billed charges,243.86,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,243.86,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,68.18,110,,3.936,fee schedule,110% of LA custom fee schedule,61.98,100,,103.264,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,160.74,38,,132.848,percent of total billed charges,38% of total billed charges,61.98,100,,3.576,Fee Schedule,100% of LA custom fee schedule,1705.94,3357,
QuantiFERON-TB Gold Plus LC,4020373,CDM,302,RC,86480,HCPCS,OUTPATIENT,,,423,253.8,,359.55,85,,287.64,Percent of total billed charges,85% of total billed charges,243.86,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,243.86,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,68.18,110,,1.024,fee schedule,110% of LA custom fee schedule,61.98,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,160.74,38,,152,percent of total billed charges,38% of total billed charges,61.98,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1706.94,3358,
TB Skin Test POC,4020375,CDM,300,RC,86580,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,29.81,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.81,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,6.94,110,,19.424,fee schedule,110% of LA custom fee schedule,6.31,100,,19.424,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,7.6,38,,152,percent of total billed charges,38% of total billed charges,6.31,100,,24.32,Fee Schedule,100% of LA custom fee schedule,1707.94,3359,
RPR LC,4020377,CDM,302,RC,86592,HCPCS,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,19.88,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.88,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,4.7,110,,17.224,fee schedule,110% of LA custom fee schedule,4.27,100,,17.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.12,38,,152,percent of total billed charges,38% of total billed charges,4.27,100,,21.568,Fee Schedule,100% of LA custom fee schedule,1708.94,3360,
"Blastomyces Abs, Qn, DID LC",4020381,CDM,302,RC,86612,HCPCS,OUTPATIENT,,,88,52.8,,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,60.16,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.16,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,14.19,110,,4.008,fee schedule,110% of LA custom fee schedule,12.9,100,,4.008,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.44,38,,152,percent of total billed charges,38% of total billed charges,12.9,100,,5.016,Fee Schedule,100% of LA custom fee schedule,1709.94,3361,
Lyme AB Total w Reflex LC,4020384,CDM,302,RC,86618,HCPCS,OUTPATIENT,,,96.48,57.888,,82.01,85,,65.608,Percent of total billed charges,85% of total billed charges,79.41,136.6,,12.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.41,136.6,,30,fee schedule,136.60% of BCBS custom fee schedule,18.73,110,,58.576,fee schedule,110% of LA custom fee schedule,17.03,100,,58.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.66,38,,152,percent of total billed charges,38% of total billed charges,17.03,100,,73.336,Fee Schedule,100% of LA custom fee schedule,1710.94,3362,
"Lyme Disease Total Antibody With Reflex to Immunoassay, LC",4020384,CDM,302,RC,86618,HCPCS,OUTPATIENT,,,96.48,57.888,,82.01,85,,65.608,Percent of total billed charges,85% of total billed charges,79.41,136.6,,30,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.41,136.6,,33.6,fee schedule,136.60% of BCBS custom fee schedule,18.73,110,,3.648,fee schedule,110% of LA custom fee schedule,17.03,100,,103.52,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.66,38,,152,percent of total billed charges,38% of total billed charges,17.03,100,,3.312,Fee Schedule,100% of LA custom fee schedule,1711.94,3363,
.Lyme IgG/IgM LC,4020384,CDM,302,RC,86618,HCPCS,OUTPATIENT,,,96.48,57.888,,82.01,85,,65.608,Percent of total billed charges,85% of total billed charges,79.41,136.6,,33.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.41,136.6,,48,fee schedule,136.60% of BCBS custom fee schedule,18.73,110,,3.448,fee schedule,110% of LA custom fee schedule,17.03,100,,3.448,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.66,38,,152,percent of total billed charges,38% of total billed charges,17.03,100,,4.32,Fee Schedule,100% of LA custom fee schedule,1712.94,3364,
"Coccidioides Abs, Qn, DID LC",4020387,CDM,302,RC,86635,HCPCS,OUTPATIENT,,,79,47.4,,67.15,85,,53.72,Percent of total billed charges,85% of total billed charges,53.48,136.6,,48,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.48,136.6,,58,fee schedule,136.60% of BCBS custom fee schedule,12.62,110,,43.736,fee schedule,110% of LA custom fee schedule,11.47,100,,43.736,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.02,38,,442.32,percent of total billed charges,38% of total billed charges,11.47,100,,54.752,Fee Schedule,100% of LA custom fee schedule,1713.94,3365,
"Cytomegalovirus (CMV) Ab, IgG LC",4020388,CDM,302,RC,86644,HCPCS,OUTPATIENT,,,99,59.4,,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,67.11,136.6,,58,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,67.11,136.6,,52.8,fee schedule,136.60% of BCBS custom fee schedule,15.83,110,,6.752,fee schedule,110% of LA custom fee schedule,14.39,100,,10.656,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,37.62,38,,684.608,percent of total billed charges,38% of total billed charges,14.39,100,,6.136,Fee Schedule,100% of LA custom fee schedule,1714.94,3366,
EBV Acute Infection Antibodies LC,4020391,CDM,302,RC,86663,HCPCS,OUTPATIENT,,,262,157.2,,222.7,85,,178.16,Percent of total billed charges,85% of total billed charges,61.17,136.6,,52.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.17,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,14.43,110,,4.6,fee schedule,110% of LA custom fee schedule,13.12,100,,4.6,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,99.56,38,,265.392,percent of total billed charges,38% of total billed charges,13.12,100,,5.76,Fee Schedule,100% of LA custom fee schedule,1715.94,3367,
"EBV Ab VCA IgM, LC",4020393,CDM,302,RC,86665,HCPCS,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,83.09,136.6,,6.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,83.09,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,19.95,110,,4.784,fee schedule,110% of LA custom fee schedule,18.14,100,,10.656,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,46.36,38,,101.84,percent of total billed charges,38% of total billed charges,18.14,100,,4.344,Fee Schedule,100% of LA custom fee schedule,1716.94,3368,
"H. pylori IgG, Abs LC",4020395,CDM,302,RC,86677,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.2,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,158,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,4.6,fee schedule,110% of LA custom fee schedule,14.15,100,,4.6,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,126.464,percent of total billed charges,38% of total billed charges,14.15,100,,5.76,Fee Schedule,100% of LA custom fee schedule,1717.94,3369,
"H. pylori IgG, Abs LC",4020395,CDM,302,RC,86677,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.2,136.6,,158,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,94.8,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,11.904,fee schedule,110% of LA custom fee schedule,14.15,100,,11.904,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,90.288,percent of total billed charges,38% of total billed charges,14.15,100,,14.904,Fee Schedule,100% of LA custom fee schedule,1718.94,3370,
"H. pylori, IgA Abs LC",4020396,CDM,302,RC,86677,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.2,136.6,,94.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,121.6,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,14.168,fee schedule,110% of LA custom fee schedule,14.15,100,,14.168,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,152,percent of total billed charges,38% of total billed charges,14.15,100,,17.736,Fee Schedule,100% of LA custom fee schedule,1719.94,3371,
"Helicobacter pylori, IgA LC",4020396,CDM,302,RC,86677,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.2,136.6,,121.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,376,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,3.32,fee schedule,110% of LA custom fee schedule,14.15,100,,3.32,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,152,percent of total billed charges,38% of total billed charges,14.15,100,,4.16,Fee Schedule,100% of LA custom fee schedule,1720.94,3372,
"H.pylori, IgM Abs LC",4020397,CDM,300,RC,86677,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.2,136.6,,376,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,245.2,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,6.608,fee schedule,110% of LA custom fee schedule,14.15,100,,6.608,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,152,percent of total billed charges,38% of total billed charges,14.15,100,,8.272,Fee Schedule,100% of LA custom fee schedule,1721.94,3373,
H Pylori AB IgM LC,4020397,CDM,300,RC,86677,HCPCS,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,54.2,136.6,,245.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,284.4,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,3.448,fee schedule,110% of LA custom fee schedule,14.15,100,,3.448,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.08,38,,152,percent of total billed charges,38% of total billed charges,14.15,100,,4.32,Fee Schedule,100% of LA custom fee schedule,1722.94,3374,
"HSV 1 IgG, Type Spec LC",4020399,CDM,302,RC,86695,HCPCS,OUTPATIENT,,,81,48.6,,68.85,85,,55.08,Percent of total billed charges,85% of total billed charges,61.5,136.6,,284.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.5,136.6,,135.2,fee schedule,136.60% of BCBS custom fee schedule,14.51,110,,0.512,fee schedule,110% of LA custom fee schedule,13.19,100,,0.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.78,38,,152,percent of total billed charges,38% of total billed charges,13.19,100,,0.64,Fee Schedule,100% of LA custom fee schedule,1723.94,3375,
"HSV 2 IgG, Type Spec LC",4020399,CDM,302,RC,86696,HCPCS,OUTPATIENT,,,119,71.4,,101.15,85,,80.92,Percent of total billed charges,85% of total billed charges,90.27,136.6,,135.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,90.27,136.6,,58,fee schedule,136.60% of BCBS custom fee schedule,21.29,110,,74.888,fee schedule,110% of LA custom fee schedule,19.35,100,,74.888,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,45.22,38,,152,percent of total billed charges,38% of total billed charges,19.35,100,,93.76,Fee Schedule,100% of LA custom fee schedule,1724.94,3376,
"HSV 1 IgG, Type Spec LC",4020399,CDM,302,RC,86695,HCPCS,OUTPATIENT,,,81,48.6,,68.85,85,,55.08,Percent of total billed charges,85% of total billed charges,61.5,136.6,,58,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.5,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,14.51,110,,59.296,fee schedule,110% of LA custom fee schedule,13.19,100,,59.296,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.78,38,,152,percent of total billed charges,38% of total billed charges,13.19,100,,74.24,Fee Schedule,100% of LA custom fee schedule,1725.94,3377,
"HSV 2 IgG, Type Spec LC",4020399,CDM,302,RC,86696,HCPCS,OUTPATIENT,,,119,71.4,,101.15,85,,80.92,Percent of total billed charges,85% of total billed charges,90.27,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,90.27,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,21.29,110,,59.296,fee schedule,110% of LA custom fee schedule,19.35,100,,59.296,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,45.22,38,,152,percent of total billed charges,38% of total billed charges,19.35,100,,74.24,Fee Schedule,100% of LA custom fee schedule,1726.94,3378,
Herpes Simplex Virus (HSV) Types 1 and 2-Specific Antibodies,4020399,CDM,302,RC,86695,HCPCS,OUTPATIENT,,,81,48.6,,68.85,85,,55.08,Percent of total billed charges,85% of total billed charges,61.5,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.5,136.6,,422,fee schedule,136.60% of BCBS custom fee schedule,14.51,110,,4.856,fee schedule,110% of LA custom fee schedule,13.19,100,,4.856,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.78,38,,54.72,percent of total billed charges,38% of total billed charges,13.19,100,,6.08,Fee Schedule,100% of LA custom fee schedule,1727.94,3379,
"86696 HSV 1 and 2 Ab, IgG LC",4020399,CDM,302,RC,86696,HCPCS,OUTPATIENT,,,119,71.4,,101.15,85,,80.92,Percent of total billed charges,85% of total billed charges,90.27,136.6,,422,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,90.27,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,21.29,110,,3.32,fee schedule,110% of LA custom fee schedule,19.35,100,,3.32,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,45.22,38,,9.12,percent of total billed charges,38% of total billed charges,19.35,100,,4.16,Fee Schedule,100% of LA custom fee schedule,1728.94,3380,
"Histoplasma Abs, Qn, DID LC",4020403,CDM,302,RC,86698,HCPCS,OUTPATIENT,,,86,51.6,,73.1,85,,58.48,Percent of total billed charges,85% of total billed charges,58.25,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,58.25,136.6,,788,fee schedule,136.60% of BCBS custom fee schedule,15.17,110,,3.472,fee schedule,110% of LA custom fee schedule,13.79,100,,3.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.68,38,,13.68,percent of total billed charges,38% of total billed charges,13.79,100,,4.344,Fee Schedule,100% of LA custom fee schedule,1729.94,3381,
Panel 083824 LC,4020404,CDM,302,RC,86701,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,41.4,136.6,,788,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,41.4,136.6,,457.6,fee schedule,136.60% of BCBS custom fee schedule,9.78,110,,0.256,fee schedule,110% of LA custom fee schedule,8.89,100,,0.256,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,21.28,percent of total billed charges,38% of total billed charges,8.89,100,,0.32,Fee Schedule,100% of LA custom fee schedule,1730.94,3382,
"Hep B Core Ab, IgM LC",4020405,CDM,302,RC,86705,HCPCS,OUTPATIENT,,,97,58.2,,82.45,85,,65.96,Percent of total billed charges,85% of total billed charges,54.84,136.6,,457.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.84,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,12.95,110,,3.344,fee schedule,110% of LA custom fee schedule,11.77,100,,3.344,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.86,38,,30.4,percent of total billed charges,38% of total billed charges,11.77,100,,4.184,Fee Schedule,100% of LA custom fee schedule,1731.94,3383,
Hep B Surface Ab LC,4020406,CDM,302,RC,86706,HCPCS,OUTPATIENT,,,61,36.6,,51.85,85,,41.48,Percent of total billed charges,85% of total billed charges,50.06,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.06,136.6,,98,fee schedule,136.60% of BCBS custom fee schedule,11.81,110,,16.36,fee schedule,110% of LA custom fee schedule,10.74,100,,16.36,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,23.18,38,,42.56,percent of total billed charges,38% of total billed charges,10.74,100,,20.48,Fee Schedule,100% of LA custom fee schedule,1732.94,3384,
"Hep A Ab, IgM LC",4020408,CDM,302,RC,86709,HCPCS,OUTPATIENT,,,77,46.2,,65.45,85,,52.36,Percent of total billed charges,85% of total billed charges,52.5,136.6,,98,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.5,136.6,,560,fee schedule,136.60% of BCBS custom fee schedule,12.39,110,,33.992,fee schedule,110% of LA custom fee schedule,11.26,100,,33.992,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,29.26,38,,9.12,percent of total billed charges,38% of total billed charges,11.26,100,,42.56,Fee Schedule,100% of LA custom fee schedule,1733.94,3385,
"Parvovirus B19, Human, IgG/IgM LC",4020412,CDM,300,RC,86747,HCPCS,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,70.08,136.6,,560,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.08,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,16.53,110,,3.576,fee schedule,110% of LA custom fee schedule,15.03,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,64.6,38,,15.2,percent of total billed charges,38% of total billed charges,15.03,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1734.94,3386,
"Rubella Antibodies, IgG LC",4020414,CDM,302,RC,86762,HCPCS,OUTPATIENT,,,73,43.8,,62.05,85,,49.64,Percent of total billed charges,85% of total billed charges,67.11,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,67.11,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,15.83,110,,79.24,fee schedule,110% of LA custom fee schedule,14.39,100,,79.24,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.74,38,,9.12,percent of total billed charges,38% of total billed charges,14.39,100,,99.2,Fee Schedule,100% of LA custom fee schedule,1735.94,3387,
"Rubeola Antibodies, IgG LC",4020415,CDM,300,RC,86765,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,60.08,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.08,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,14.17,110,,3.656,fee schedule,110% of LA custom fee schedule,12.88,100,,10.656,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.7,38,,15.2,percent of total billed charges,38% of total billed charges,12.88,100,,3.32,Fee Schedule,100% of LA custom fee schedule,1736.94,3388,
"Rocky Mtn Spotted Fever, IgM LC",4020418,CDM,300,RC,86787,HCPCS,OUTPATIENT,,,132,79.2,,112.2,85,,89.76,Percent of total billed charges,85% of total billed charges,52.28,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.28,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,14.17,110,,1.136,fee schedule,110% of LA custom fee schedule,12.88,100,,105.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,50.16,38,,32.832,percent of total billed charges,38% of total billed charges,12.88,100,,1.032,Fee Schedule,100% of LA custom fee schedule,1737.94,3389,
"Varicella-Zoster V Ab, IgG LC",4020419,CDM,302,RC,86787,HCPCS,OUTPATIENT,,,89,53.4,,75.65,85,,60.52,Percent of total billed charges,85% of total billed charges,52.28,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.28,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,14.17,110,,9.712,fee schedule,110% of LA custom fee schedule,12.88,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.82,38,,137.408,percent of total billed charges,38% of total billed charges,12.88,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1738.94,3390,
Varicella-Zoster IgM Ab  LC,4020420,CDM,300,RC,86787,HCPCS,OUTPATIENT,,,89,53.4,,75.65,85,,60.52,Percent of total billed charges,85% of total billed charges,52.28,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.28,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,14.17,110,,2.696,fee schedule,110% of LA custom fee schedule,12.88,100,,2.696,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.82,38,,97.28,percent of total billed charges,38% of total billed charges,12.88,100,,3.376,Fee Schedule,100% of LA custom fee schedule,1739.94,3391,
West Nile Virus LC,4020421,CDM,302,RC,86788,HCPCS,OUTPATIENT,,,182,109.2,,154.7,85,,123.76,Percent of total billed charges,85% of total billed charges,66.29,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.29,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,18.54,110,,5.344,fee schedule,110% of LA custom fee schedule,16.85,100,,105.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,69.16,38,,124.032,percent of total billed charges,38% of total billed charges,16.85,100,,4.856,Fee Schedule,100% of LA custom fee schedule,1740.94,3392,
"West Nile Virus Antibody, CSF LC",4020421,CDM,302,RC,86788,HCPCS,OUTPATIENT,,,182,109.2,,154.7,85,,123.76,Percent of total billed charges,85% of total billed charges,66.29,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.29,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,18.54,110,,3.576,fee schedule,110% of LA custom fee schedule,16.85,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,69.16,38,,100.624,percent of total billed charges,38% of total billed charges,16.85,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1741.94,3393,
Antithyroglobulin Ab LC,4020422,CDM,301,RC,86800,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,74.15,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.15,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,17.5,110,,6.328,fee schedule,110% of LA custom fee schedule,15.91,100,,6.328,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.2,38,,1.824,percent of total billed charges,38% of total billed charges,15.91,100,,7.92,Fee Schedule,100% of LA custom fee schedule,1742.94,3394,
Thyroglobulin Antibody LC,4020422,CDM,301,RC,86800,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,74.15,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.15,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,17.5,110,,2.216,fee schedule,110% of LA custom fee schedule,15.91,100,,2.216,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.2,38,,50.464,percent of total billed charges,38% of total billed charges,15.91,100,,2.776,Fee Schedule,100% of LA custom fee schedule,1743.94,3395,
82088-Aldosterone/Renin Ratio,4020423,CDM,301,RC,82088,HCPCS,OUTPATIENT,,,230.88,138.528,,196.25,85,,157,Percent of total billed charges,85% of total billed charges,190,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,190,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,44.83,110,,47.8,fee schedule,110% of LA custom fee schedule,40.75,100,,47.8,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,87.73,38,,1.52,percent of total billed charges,38% of total billed charges,40.75,100,,59.84,Fee Schedule,100% of LA custom fee schedule,1744.94,3396,
HCV Antibody LC,4020425,CDM,302,RC,86803,HCPCS,OUTPATIENT,,,80.88,48.528,,68.75,85,,55,Percent of total billed charges,85% of total billed charges,66.52,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.52,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,15.7,110,,0.256,fee schedule,110% of LA custom fee schedule,14.27,100,,0.256,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.73,38,,5.168,percent of total billed charges,38% of total billed charges,14.27,100,,0.32,Fee Schedule,100% of LA custom fee schedule,1745.94,3397,
HCV Antibody RFX to Quant PCR LC,4020425,CDM,300,RC,86803,HCPCS,OUTPATIENT,,,80.88,48.528,,68.75,85,,55,Percent of total billed charges,85% of total billed charges,66.52,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,66.52,136.6,,50,fee schedule,136.60% of BCBS custom fee schedule,15.7,110,,40.872,fee schedule,110% of LA custom fee schedule,14.27,100,,40.872,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.73,38,,3.648,percent of total billed charges,38% of total billed charges,14.27,100,,51.168,Fee Schedule,100% of LA custom fee schedule,1746.94,3398,
AB ID,4020427,CDM,302,RC,86850,HCPCS,OUTPATIENT,,,475,285,,403.75,85,,323,Percent of total billed charges,85% of total billed charges,31.76,136.6,,50,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,31.76,136.6,,62,fee schedule,136.60% of BCBS custom fee schedule,7.41,110,,31.952,fee schedule,110% of LA custom fee schedule,6.74,100,,31.952,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,180.5,38,,3.648,percent of total billed charges,38% of total billed charges,6.74,100,,40,Fee Schedule,100% of LA custom fee schedule,1747.94,3399,
RBC ANTIBODY ELUTION,4020428,CDM,302,RC,86860,HCPCS,OUTPATIENT,,,516,309.6,,438.6,85,,350.88,Percent of total billed charges,85% of total billed charges,32.85,136.6,,62,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.85,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,15.99,110,,1.024,fee schedule,110% of LA custom fee schedule,14.54,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,196.08,38,,3.648,percent of total billed charges,38% of total billed charges,14.54,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1748.94,3400,
Direct Coombs,4020432,CDM,302,RC,86880,HCPCS,OUTPATIENT,,,42.36,25.416,,36.01,85,,28.808,Percent of total billed charges,85% of total billed charges,25.03,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.03,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,5.93,110,,31.184,fee schedule,110% of LA custom fee schedule,5.39,100,,31.184,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.1,38,,5.472,percent of total billed charges,38% of total billed charges,5.39,100,,39.04,Fee Schedule,100% of LA custom fee schedule,1749.94,3401,
Coombs' Direct LC,4020432,CDM,302,RC,86880,HCPCS,OUTPATIENT,,,42.36,25.416,,36.01,85,,28.808,Percent of total billed charges,85% of total billed charges,25.03,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.03,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,5.93,110,,2.528,fee schedule,110% of LA custom fee schedule,5.39,100,,10.736,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,16.1,38,,5.512,percent of total billed charges,38% of total billed charges,5.39,100,,2.304,Fee Schedule,100% of LA custom fee schedule,1750.94,3402,
Per AG Group 2,4020437,CDM,309,RC,86905,HCPCS,OUTPATIENT,,,1546,927.6,,1314.1,85,,1051.28,Percent of total billed charges,85% of total billed charges,17.83,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.83,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,4.21,110,,1.28,fee schedule,110% of LA custom fee schedule,3.83,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,587.48,38,,5.512,percent of total billed charges,38% of total billed charges,3.83,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1751.94,3403,
"Blood Culture, Routine LC",4020444,CDM,306,RC,87040,HCPCS,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,48.11,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,48.11,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,11.35,110,,1.28,fee schedule,110% of LA custom fee schedule,10.32,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,3.648,percent of total billed charges,38% of total billed charges,10.32,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1752.94,3404,
Stool Culture LC,4020445,CDM,306,RC,87045,HCPCS,OUTPATIENT,,,54,32.4,,45.9,85,,36.72,Percent of total billed charges,85% of total billed charges,43.97,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.97,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,10.38,110,,0.872,fee schedule,110% of LA custom fee schedule,9.44,100,,10.736,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.52,38,,3.648,percent of total billed charges,38% of total billed charges,9.44,100,,0.792,Fee Schedule,100% of LA custom fee schedule,1753.94,3405,
"Yersinia Only, Stool Culture",4020446,CDM,306,RC,87046,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,43.97,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.97,136.6,,486,fee schedule,136.60% of BCBS custom fee schedule,3.92,110,,3.024,fee schedule,110% of LA custom fee schedule,3.56,100,,10.736,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.7,38,,3.648,percent of total billed charges,38% of total billed charges,3.56,100,,2.744,Fee Schedule,100% of LA custom fee schedule,1754.94,3406,
Aerobic Bacterial Culture LC,4020447,CDM,306,RC,87070,HCPCS,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,40.15,136.6,,486,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.15,136.6,,486,fee schedule,136.60% of BCBS custom fee schedule,9.48,110,,11.528,fee schedule,110% of LA custom fee schedule,8.62,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.62,38,,3.648,percent of total billed charges,38% of total billed charges,8.62,100,,10.48,Fee Schedule,100% of LA custom fee schedule,1755.94,3407,
"Body Fluid Culture, Sterile LC",4020450,CDM,306,RC,87070,HCPCS,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,40.15,136.6,,486,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.15,136.6,,450,fee schedule,136.60% of BCBS custom fee schedule,9.48,110,,0.512,fee schedule,110% of LA custom fee schedule,8.62,100,,0.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.62,38,,3.648,percent of total billed charges,38% of total billed charges,8.62,100,,0.64,Fee Schedule,100% of LA custom fee schedule,1756.94,3408,
"Genital Culture, Routine LC",4020451,CDM,306,RC,87070,HCPCS,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,40.15,136.6,,450,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.15,136.6,,610,fee schedule,136.60% of BCBS custom fee schedule,9.48,110,,25.024,fee schedule,110% of LA custom fee schedule,8.62,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.62,38,,3.648,percent of total billed charges,38% of total billed charges,8.62,100,,22.752,Fee Schedule,100% of LA custom fee schedule,1757.94,3409,
Lower Respiratory Culture LC,4020454,CDM,306,RC,87070,HCPCS,OUTPATIENT,,,87,52.2,,73.95,85,,59.16,Percent of total billed charges,85% of total billed charges,40.15,136.6,,610,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.15,136.6,,66,fee schedule,136.60% of BCBS custom fee schedule,9.48,110,,10.688,fee schedule,110% of LA custom fee schedule,8.62,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.06,38,,3.648,percent of total billed charges,38% of total billed charges,8.62,100,,9.712,Fee Schedule,100% of LA custom fee schedule,1758.94,3410,
"Smear, primary source with interpretation; Gram or Giemsa st",4020454,CDM,306,RC,87205,HCPCS,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,19.88,136.6,,66,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.88,136.6,,179.2,fee schedule,136.60% of BCBS custom fee schedule,4.7,110,,10.48,fee schedule,110% of LA custom fee schedule,4.27,100,,10.48,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.8,38,,3.648,percent of total billed charges,38% of total billed charges,4.27,100,,13.12,Fee Schedule,100% of LA custom fee schedule,1759.94,3411,
Upper Respiratory Culture LC,4020456,CDM,301,RC,87070,HCPCS,OUTPATIENT,,,87,52.2,,73.95,85,,59.16,Percent of total billed charges,85% of total billed charges,40.15,136.6,,179.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.15,136.6,,231.2,fee schedule,136.60% of BCBS custom fee schedule,9.48,110,,9.456,fee schedule,110% of LA custom fee schedule,8.62,100,,9.456,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.06,38,,6.624,percent of total billed charges,38% of total billed charges,8.62,100,,11.84,Fee Schedule,100% of LA custom fee schedule,1760.94,3412,
Anaerobic Culture LC,4020458,CDM,306,RC,87075,HCPCS,OUTPATIENT,,,54,32.4,,45.9,85,,36.72,Percent of total billed charges,85% of total billed charges,44.12,136.6,,231.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,44.12,136.6,,231.2,fee schedule,136.60% of BCBS custom fee schedule,10.42,110,,8.688,fee schedule,110% of LA custom fee schedule,9.47,100,,8.688,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.52,38,,9.704,percent of total billed charges,38% of total billed charges,9.47,100,,10.88,Fee Schedule,100% of LA custom fee schedule,1761.94,3413,
Anaerobe Identification Only LC,4020459,CDM,306,RC,87076,HCPCS,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,37.69,136.6,,231.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,37.69,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,8.89,110,,6.952,fee schedule,110% of LA custom fee schedule,8.08,100,,6.952,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.48,38,,6.616,percent of total billed charges,38% of total billed charges,8.08,100,,8.704,Fee Schedule,100% of LA custom fee schedule,1762.94,3414,
Bill Organism ID,4020461,CDM,306,RC,87077,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,37.69,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,37.69,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,8.89,110,,7.416,fee schedule,110% of LA custom fee schedule,8.08,100,,7.416,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.1,38,,6.624,percent of total billed charges,38% of total billed charges,8.08,100,,9.28,Fee Schedule,100% of LA custom fee schedule,1763.94,3415,
Organism Id,4020461,CDM,306,RC,87077,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,37.69,136.6,,12.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,37.69,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,8.89,110,,7.16,fee schedule,110% of LA custom fee schedule,8.08,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.1,38,,8.44,percent of total billed charges,38% of total billed charges,8.08,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1764.94,3416,
MRSA Screening Culture LC,4020463,CDM,300,RC,87081,HCPCS,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,30.89,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.89,136.6,,81.2,fee schedule,136.60% of BCBS custom fee schedule,7.29,110,,1.688,fee schedule,110% of LA custom fee schedule,6.63,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.48,38,,3.648,percent of total billed charges,38% of total billed charges,6.63,100,,1.536,Fee Schedule,100% of LA custom fee schedule,1765.94,3417,
"Urine Culture, Routine LC",4020466,CDM,306,RC,87086,HCPCS,OUTPATIENT,,,64,38.4,,54.4,85,,43.52,Percent of total billed charges,85% of total billed charges,37.63,136.6,,81.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,37.63,136.6,,860,fee schedule,136.60% of BCBS custom fee schedule,8.88,110,,4.856,fee schedule,110% of LA custom fee schedule,8.07,100,,4.856,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,24.32,38,,6.624,percent of total billed charges,38% of total billed charges,8.07,100,,6.08,Fee Schedule,100% of LA custom fee schedule,1766.94,3418,
URINE CX W PRESUMP ID,4020467,CDM,306,RC,87088,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,37.76,136.6,,860,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,37.76,136.6,,960,fee schedule,136.60% of BCBS custom fee schedule,8.9,110,,4.856,fee schedule,110% of LA custom fee schedule,8.09,100,,4.856,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.1,38,,6.616,percent of total billed charges,38% of total billed charges,8.09,100,,6.08,Fee Schedule,100% of LA custom fee schedule,1767.94,3419,
Bill Presumptive ID,4020467,CDM,306,RC,87088,HCPCS,OUTPATIENT,,,45.88,27.528,,39,85,,31.2,Percent of total billed charges,85% of total billed charges,37.76,136.6,,960,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,37.76,136.6,,860,fee schedule,136.60% of BCBS custom fee schedule,8.9,110,,6.136,fee schedule,110% of LA custom fee schedule,8.09,100,,6.136,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,17.43,38,,11.728,percent of total billed charges,38% of total billed charges,8.09,100,,7.68,Fee Schedule,100% of LA custom fee schedule,1768.94,3420,
Fungus (Mycology) Culture LC,4020469,CDM,306,RC,87101,HCPCS,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,32.98,136.6,,860,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.98,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,8.48,110,,6.904,fee schedule,110% of LA custom fee schedule,7.71,100,,6.904,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,15.2,38,,6.36,percent of total billed charges,38% of total billed charges,7.71,100,,8.64,Fee Schedule,100% of LA custom fee schedule,1769.94,3421,
Acid Fast Smear+Culture LC,4020474,CDM,306,RC,87116,HCPCS,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,50.38,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.38,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,11.88,110,,217.616,fee schedule,110% of LA custom fee schedule,10.8,100,,217.616,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.12,38,,6.624,percent of total billed charges,38% of total billed charges,10.8,100,,272.448,Fee Schedule,100% of LA custom fee schedule,1770.94,3422,
Ova + Parasite Exam LC,4020480,CDM,306,RC,87177,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,40.79,136.6,,18.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.79,136.6,,24.8,fee schedule,136.60% of BCBS custom fee schedule,9.79,110,,0.768,fee schedule,110% of LA custom fee schedule,8.9,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,6.616,percent of total billed charges,38% of total billed charges,8.9,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1771.94,3423,
"Susceptibility, Anaerobic LC",4020481,CDM,300,RC,87186,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,40.32,136.6,,24.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.32,136.6,,514,fee schedule,136.60% of BCBS custom fee schedule,9.52,110,,103.496,fee schedule,110% of LA custom fee schedule,8.65,100,,103.496,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,76,38,,6.36,percent of total billed charges,38% of total billed charges,8.65,100,,129.568,Fee Schedule,100% of LA custom fee schedule,1772.94,3424,
"Susceptibility, Aer + Anaerob LC",4020484,CDM,306,RC,87186,HCPCS,OUTPATIENT,,,59,35.4,91,50.15,85,,40.12,Percent of total billed charges,85% of total billed charges,40.32,136.6,,514,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.32,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,9.52,110,,10.48,fee schedule,110% of LA custom fee schedule,8.65,100,,10.48,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.42,38,,4.688,percent of total billed charges,38% of total billed charges,8.65,100,,13.12,Fee Schedule,100% of LA custom fee schedule,1773.94,3425,
Bill Suscepitibility Testing,4020484,CDM,306,RC,87186,HCPCS,OUTPATIENT,,,59,35.4,91,50.15,85,,40.12,Percent of total billed charges,85% of total billed charges,40.32,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.32,136.6,,16.8,fee schedule,136.60% of BCBS custom fee schedule,9.52,110,,8.624,fee schedule,110% of LA custom fee schedule,8.65,100,,8.624,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.42,38,,3.648,percent of total billed charges,38% of total billed charges,8.65,100,,10.8,Fee Schedule,100% of LA custom fee schedule,1774.94,3426,
Gram Stain LC,4020486,CDM,306,RC,87205,HCPCS,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,19.88,136.6,,16.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.88,136.6,,122,fee schedule,136.60% of BCBS custom fee schedule,4.7,110,,30.144,fee schedule,110% of LA custom fee schedule,4.27,100,,30.144,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.8,38,,3.648,percent of total billed charges,38% of total billed charges,4.27,100,,37.736,Fee Schedule,100% of LA custom fee schedule,1775.94,3427,
WET PREP,4020491,CDM,306,RC,87210,HCPCS,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,19.88,136.6,,122,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.88,136.6,,250,fee schedule,136.60% of BCBS custom fee schedule,6.05,110,,0.256,fee schedule,110% of LA custom fee schedule,5.5,100,,0.256,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.12,38,,3.648,percent of total billed charges,38% of total billed charges,5.5,100,,0.32,Fee Schedule,100% of LA custom fee schedule,1776.94,3428,
HSV Culture and Typing LC,4020493,CDM,306,RC,87255,HCPCS,OUTPATIENT,,,192,115.2,,163.2,85,,130.56,Percent of total billed charges,85% of total billed charges,157.87,136.6,,250,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,157.87,136.6,,50,fee schedule,136.60% of BCBS custom fee schedule,37.25,110,,1.408,fee schedule,110% of LA custom fee schedule,33.86,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,72.96,38,,3.648,percent of total billed charges,38% of total billed charges,33.86,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1777.94,3429,
C Diff,4020496,CDM,306,RC,87324,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.91,136.6,,50,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,132,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,0.768,fee schedule,110% of LA custom fee schedule,11.98,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,3.648,percent of total billed charges,38% of total billed charges,11.98,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1778.94,3430,
C-DIFF,4020496,CDM,306,RC,87324,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.91,136.6,,132,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,38,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,11.832,fee schedule,110% of LA custom fee schedule,11.98,100,,11.832,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,3.648,percent of total billed charges,38% of total billed charges,11.98,100,,14.816,Fee Schedule,100% of LA custom fee schedule,1779.94,3431,
C Diff Ag and Toxin,4020496,CDM,306,RC,87324,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.91,136.6,,38,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,128,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,5.264,fee schedule,110% of LA custom fee schedule,11.98,100,,5.264,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,3.648,percent of total billed charges,38% of total billed charges,11.98,100,,6.584,Fee Schedule,100% of LA custom fee schedule,1780.94,3432,
Cryptosporidium EIA,4020497,CDM,306,RC,87328,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.91,136.6,,128,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,151.2,fee schedule,136.60% of BCBS custom fee schedule,15.2,110,,2.048,fee schedule,110% of LA custom fee schedule,13.82,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,17.632,percent of total billed charges,38% of total billed charges,13.82,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1781.94,3433,
"Giardia Lamblia Direct Detection EIA, LC",4020498,CDM,306,RC,87329,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.91,136.6,,151.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,54,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,1.28,fee schedule,110% of LA custom fee schedule,11.98,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,3.648,percent of total billed charges,38% of total billed charges,11.98,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1782.94,3434,
Giardia/Cryptosporidium EIA LC,4020498,CDM,306,RC,87329,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.91,136.6,,54,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,4.488,fee schedule,110% of LA custom fee schedule,11.98,100,,4.488,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,3.648,percent of total billed charges,38% of total billed charges,11.98,100,,5.616,Fee Schedule,100% of LA custom fee schedule,1783.94,3435,
"H. pylori Stool Ag, EIA LC",4020500,CDM,306,RC,87338,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,21.68,136.6,,21.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.68,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,7.11,110,,1.792,fee schedule,110% of LA custom fee schedule,6.46,100,,1.792,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,37.24,38,,8.144,percent of total billed charges,38% of total billed charges,6.46,100,,2.24,Fee Schedule,100% of LA custom fee schedule,1784.94,3436,
HBsAg Screen LC,4020501,CDM,306,RC,87340,HCPCS,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,48.15,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,48.15,136.6,,210,fee schedule,136.60% of BCBS custom fee schedule,11.36,110,,1.28,fee schedule,110% of LA custom fee schedule,10.33,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.12,38,,11.552,percent of total billed charges,38% of total billed charges,10.33,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1785.94,3437,
HIV 4th Gen Screen w Reflex LC,4020504,CDM,306,RC,87389,HCPCS,OUTPATIENT,,,164,98.4,,139.4,85,,111.52,Percent of total billed charges,85% of total billed charges,89.68,136.6,,210,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,89.68,136.6,,173.6,fee schedule,136.60% of BCBS custom fee schedule,26.49,110,,9.712,fee schedule,110% of LA custom fee schedule,24.08,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,62.32,38,,6.08,percent of total billed charges,38% of total billed charges,24.08,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1786.94,3438,
"Rotavirus Ag, EIA LC",4020507,CDM,306,RC,87425,HCPCS,OUTPATIENT,,,67.96,40.776,,57.77,85,,46.216,Percent of total billed charges,85% of total billed charges,55.91,136.6,,173.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,173.6,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,29.448,fee schedule,110% of LA custom fee schedule,11.98,100,,29.448,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.82,38,,13.984,percent of total billed charges,38% of total billed charges,11.98,100,,36.864,Fee Schedule,100% of LA custom fee schedule,1787.94,3439,
L. pneumophila Serogp 1 Ur Ag LC,4020509,CDM,306,RC,87449,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.91,136.6,,173.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,88.336,fee schedule,110% of LA custom fee schedule,11.98,100,,88.336,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,1.824,percent of total billed charges,38% of total billed charges,11.98,100,,110.592,Fee Schedule,100% of LA custom fee schedule,1788.94,3440,
L. pneumophila Serogp 1 Ur Ag LC Add On,4020509,CDM,306,RC,87449,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.91,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,57.512,fee schedule,110% of LA custom fee schedule,11.98,100,,57.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,1.216,percent of total billed charges,38% of total billed charges,11.98,100,,72,Fee Schedule,100% of LA custom fee schedule,1789.94,3441,
C Diff,4020509,CDM,306,RC,87324,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.91,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,368,fee schedule,136.60% of BCBS custom fee schedule,13.18,110,,48.312,fee schedule,110% of LA custom fee schedule,11.98,100,,48.312,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,7.6,percent of total billed charges,38% of total billed charges,11.98,100,,60.48,Fee Schedule,100% of LA custom fee schedule,1790.94,3442,
"Chlamydia trachomatis, NAA LC",4020512,CDM,306,RC,87491,HCPCS,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,163.65,136.6,,368,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,270,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,3.32,fee schedule,110% of LA custom fee schedule,35.09,100,,3.32,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,91.2,38,,28.272,percent of total billed charges,38% of total billed charges,35.09,100,,4.16,Fee Schedule,100% of LA custom fee schedule,1791.94,3443,
"Chlamydia trachomatis, NAA LC",4020512,CDM,306,RC,87491,HCPCS,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,163.65,136.6,,270,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,420,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,5.368,fee schedule,110% of LA custom fee schedule,35.09,100,,5.368,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,91.2,38,,27.664,percent of total billed charges,38% of total billed charges,35.09,100,,6.72,Fee Schedule,100% of LA custom fee schedule,1792.94,3444,
CMV PCR LC,4020514,CDM,306,RC,87496,HCPCS,OUTPATIENT,,,177,106.2,,150.45,85,,120.36,Percent of total billed charges,85% of total billed charges,163.65,136.6,,420,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,86,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,5.112,fee schedule,110% of LA custom fee schedule,35.09,100,,5.112,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,67.26,38,,27.664,percent of total billed charges,38% of total billed charges,35.09,100,,6.4,Fee Schedule,100% of LA custom fee schedule,1793.94,3445,
INFLUENZA DNA AMP PROBE 87502,4020515,CDM,306,RC,87502,HCPCS,OUTPATIENT,,,174,104.4,,147.9,85,,118.32,Percent of total billed charges,85% of total billed charges,337.27,136.6,,86,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,337.27,136.6,,150,fee schedule,136.60% of BCBS custom fee schedule,105.38,110,,7.328,fee schedule,110% of LA custom fee schedule,95.8,100,,7.328,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,66.12,38,,27.664,percent of total billed charges,38% of total billed charges,95.8,100,,9.176,Fee Schedule,100% of LA custom fee schedule,1794.94,3446,
HCV RNA PCR Qn Rfx NS3/4A LC,4020517,CDM,306,RC,87522,HCPCS,OUTPATIENT,,,293,175.8,,249.05,85,,199.24,Percent of total billed charges,85% of total billed charges,199.7,136.6,,150,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.7,136.6,,38,fee schedule,136.60% of BCBS custom fee schedule,47.12,110,,101.608,fee schedule,110% of LA custom fee schedule,42.84,100,,101.608,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,111.34,38,,22.496,percent of total billed charges,38% of total billed charges,42.84,100,,127.208,Fee Schedule,100% of LA custom fee schedule,1795.94,3447,
HCV RT-PCR Qn (Non-Graph) LC,4020517,CDM,300,RC,87522,HCPCS,OUTPATIENT,,,293,175.8,,249.05,85,,199.24,Percent of total billed charges,85% of total billed charges,199.7,136.6,,38,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.7,136.6,,38,fee schedule,136.60% of BCBS custom fee schedule,47.12,110,,357.84,fee schedule,110% of LA custom fee schedule,42.84,100,,357.84,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,111.34,38,,10.032,percent of total billed charges,38% of total billed charges,42.84,100,,448,Fee Schedule,100% of LA custom fee schedule,1796.94,3448,
87522-Hepatitis Panel (4) LC,4020517,CDM,300,RC,87522,HCPCS,OUTPATIENT,,,293,175.8,,249.05,85,,199.24,Percent of total billed charges,85% of total billed charges,199.7,136.6,,38,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.7,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,47.12,110,,9.712,fee schedule,110% of LA custom fee schedule,42.84,100,,9.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,111.34,38,,11.552,percent of total billed charges,38% of total billed charges,42.84,100,,12.16,Fee Schedule,100% of LA custom fee schedule,1797.94,3449,
HSV 1/2 PCR LC,4020518,CDM,306,RC,87529,HCPCS,OUTPATIENT,,,199,119.4,,169.15,85,,135.32,Percent of total billed charges,85% of total billed charges,163.65,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,3.576,fee schedule,110% of LA custom fee schedule,35.09,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,75.62,38,,4.864,percent of total billed charges,38% of total billed charges,35.09,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1798.94,3450,
"HIV Quant, LC",4020521,CDM,300,RC,87536,HCPCS,OUTPATIENT,,,482.08,289.248,,409.77,85,,327.816,Percent of total billed charges,85% of total billed charges,396.71,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,396.71,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,93.4,110,,8.432,fee schedule,110% of LA custom fee schedule,84.91,100,,8.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,183.19,38,,27.36,percent of total billed charges,38% of total billed charges,84.91,100,,10.56,Fee Schedule,100% of LA custom fee schedule,1799.94,3451,
"Monkeypox (Orthopoxvirus), PCR LC",4020522,CDM,306,RC,87593,HCPCS,OUTPATIENT,,,154,92.4,,130.9,85,,104.72,Percent of total billed charges,85% of total billed charges,70.09,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.09,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,42.33,110,,32.208,fee schedule,110% of LA custom fee schedule,38.48,100,,32.208,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,58.52,38,,27.36,percent of total billed charges,38% of total billed charges,38.48,100,,40.32,Fee Schedule,100% of LA custom fee schedule,1800.94,3452,
ORTHOPOXVIRUS PCR,4020522,CDM,306,RC,87593,HCPCS,OUTPATIENT,,,154,92.4,,130.9,85,,104.72,Percent of total billed charges,85% of total billed charges,70.09,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.09,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,42.33,110,,146.712,fee schedule,110% of LA custom fee schedule,38.48,100,,146.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,58.52,38,,21.312,percent of total billed charges,38% of total billed charges,38.48,100,,183.68,Fee Schedule,100% of LA custom fee schedule,1801.94,3453,
"Neisseria gonorrhoeae, NAA LC",4020523,CDM,306,RC,87591,HCPCS,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,163.65,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,15.552,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,146.712,fee schedule,110% of LA custom fee schedule,35.09,100,,146.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,91.2,38,,4.256,percent of total billed charges,38% of total billed charges,35.09,100,,183.68,Fee Schedule,100% of LA custom fee schedule,1802.94,3454,
"Neisseria gonorrhoeae, NAA LC",4020523,CDM,306,RC,87591,HCPCS,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,163.65,136.6,,15.552,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,2160,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,2.048,fee schedule,110% of LA custom fee schedule,35.09,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,91.2,38,,197.6,percent of total billed charges,38% of total billed charges,35.09,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1803.94,3455,
B.pertussisB.parapertussis PCR LC,4020524,CDM,306,RC,87798,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,2160,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,416.4,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,25.56,fee schedule,110% of LA custom fee schedule,35.09,100,,25.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,1.52,percent of total billed charges,38% of total billed charges,35.09,100,,32,Fee Schedule,100% of LA custom fee schedule,1804.94,3456,
B.pertussis B.parapertussis PCR,4020524,CDM,306,RC,87798,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,416.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,114,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,0.768,fee schedule,110% of LA custom fee schedule,35.09,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,0.304,percent of total billed charges,38% of total billed charges,35.09,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1805.94,3457,
Bordetella pertussis -BioFire,4020524,CDM,306,RC,87798,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,114,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,58,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,0.768,fee schedule,110% of LA custom fee schedule,35.09,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,1.52,percent of total billed charges,38% of total billed charges,35.09,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1806.94,3458,
BK Quant PCR (Plasma/Serum) LC,4020526,CDM,306,RC,87799,HCPCS,OUTPATIENT,,,292,175.2,,248.2,85,,198.56,Percent of total billed charges,85% of total billed charges,199.7,136.6,,58,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.7,136.6,,192,fee schedule,136.60% of BCBS custom fee schedule,18.37,110,,0.768,fee schedule,110% of LA custom fee schedule,16.7,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,110.96,38,,5.816,percent of total billed charges,38% of total billed charges,16.7,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1807.94,3459,
"EBV, Chronic/Active Infection LC",4020526,CDM,306,RC,87799,HCPCS,OUTPATIENT,,,292,175.2,,248.2,85,,198.56,Percent of total billed charges,85% of total billed charges,199.7,136.6,,192,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.7,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,18.37,110,,28.848,fee schedule,110% of LA custom fee schedule,16.7,100,,28.848,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,110.96,38,,4.184,percent of total billed charges,38% of total billed charges,16.7,100,,36.112,Fee Schedule,100% of LA custom fee schedule,1808.94,3460,
Bacterial Antigens LC,4020527,CDM,306,RC,87802,HCPCS,OUTPATIENT,,,135.92,81.552,,115.53,85,,92.424,Percent of total billed charges,85% of total billed charges,55.91,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,14,110,,21.472,fee schedule,110% of LA custom fee schedule,12.73,100,,21.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.65,38,,35.872,percent of total billed charges,38% of total billed charges,12.73,100,,26.88,Fee Schedule,100% of LA custom fee schedule,1809.94,3461,
Influenza A/B POC,4020528,CDM,300,RC,87804,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,55.91,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,17.8,110,,0.768,fee schedule,110% of LA custom fee schedule,16.18,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,0.304,percent of total billed charges,38% of total billed charges,16.18,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1810.94,3462,
RSV,4020529,CDM,306,RC,87807,HCPCS,OUTPATIENT,,,67.96,40.776,,57.77,85,,46.216,Percent of total billed charges,85% of total billed charges,55.91,136.6,,28,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,155.2,fee schedule,136.60% of BCBS custom fee schedule,14.41,110,,9.664,fee schedule,110% of LA custom fee schedule,13.1,100,,9.664,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.82,38,,20.272,percent of total billed charges,38% of total billed charges,13.1,100,,12.096,Fee Schedule,100% of LA custom fee schedule,1811.94,3463,
RSV POC,4020529,CDM,300,RC,87807,HCPCS,OUTPATIENT,,,123,73.8,,104.55,85,,83.64,Percent of total billed charges,85% of total billed charges,55.91,136.6,,155.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,52,fee schedule,136.60% of BCBS custom fee schedule,14.41,110,,2.528,fee schedule,110% of LA custom fee schedule,13.1,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,46.74,38,,4.256,percent of total billed charges,38% of total billed charges,13.1,100,,2.304,Fee Schedule,100% of LA custom fee schedule,1812.94,3464,
RAPID STREP SCREEN,4020530,CDM,306,RC,87880,HCPCS,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,55.91,136.6,,52,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,120,fee schedule,136.60% of BCBS custom fee schedule,17.8,110,,7.032,fee schedule,110% of LA custom fee schedule,16.18,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,127.72,percent of total billed charges,38% of total billed charges,16.18,100,,6.392,Fee Schedule,100% of LA custom fee schedule,1813.94,3465,
"Cryptococcus Antigen, Serum LC",4020531,CDM,306,RC,87899,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,55.91,136.6,,120,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,150,fee schedule,136.60% of BCBS custom fee schedule,17.68,110,,7.592,fee schedule,110% of LA custom fee schedule,16.07,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,4.56,percent of total billed charges,38% of total billed charges,16.07,100,,6.904,Fee Schedule,100% of LA custom fee schedule,1814.94,3466,
"Cell Ct, Body Fluid LC",4020545,CDM,300,RC,89051,HCPCS,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,25.71,136.6,,150,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.71,136.6,,151.2,fee schedule,136.60% of BCBS custom fee schedule,6.16,110,,0.512,fee schedule,110% of LA custom fee schedule,5.6,100,,0.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,14.44,38,,127.72,percent of total billed charges,38% of total billed charges,5.6,100,,0.64,Fee Schedule,100% of LA custom fee schedule,1815.94,3467,
"Cell Count, CSF LC",4020546,CDM,300,RC,89051,HCPCS,OUTPATIENT,,,31.2,18.72,,26.52,85,,21.216,Percent of total billed charges,85% of total billed charges,25.71,136.6,,151.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.71,136.6,,112,fee schedule,136.60% of BCBS custom fee schedule,6.16,110,,0.512,fee schedule,110% of LA custom fee schedule,5.6,100,,0.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.86,38,,102.6,percent of total billed charges,38% of total billed charges,5.6,100,,0.64,Fee Schedule,100% of LA custom fee schedule,1816.94,3468,
"White Blood Cells (WBC), Stool LC",4020548,CDM,309,RC,89055,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,19.88,136.6,,112,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.88,136.6,,112,fee schedule,136.60% of BCBS custom fee schedule,4.7,110,,1.28,fee schedule,110% of LA custom fee schedule,4.27,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.4,38,,16.176,percent of total billed charges,38% of total billed charges,4.27,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1817.94,3469,
"Cell count, Synovial w crystals, LC",4020549,CDM,300,RC,89060,HCPCS,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,33.34,136.6,,112,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,33.34,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,8.06,110,,2.304,fee schedule,110% of LA custom fee schedule,7.33,100,,2.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,18.62,38,,60.8,percent of total billed charges,38% of total billed charges,7.33,100,,2.88,Fee Schedule,100% of LA custom fee schedule,1818.94,3470,
SEMEN ANALYSIS SPERM DETECTION,4020551,CDM,309,RC,89321,HCPCS,OUTPATIENT,,,83,49.8,,70.55,85,,56.44,Percent of total billed charges,85% of total billed charges,56.2,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.2,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,26.52,31.95,,250.488,percent of total billed charges,31.95% of total billed charges,26.52,31.95,,250.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.54,38,,3.048,percent of total billed charges,38% of total billed charges,33.2,40,,313.6,percent of total billed charges,40% of total billed charges,1819.94,3471,
Free T4 by Dialysis/Mass Spec,4020552,CDM,301,RC,84439,HCPCS,OUTPATIENT,,,154,92.4,,130.9,85,,104.72,Percent of total billed charges,85% of total billed charges,42.03,136.6,,9.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,42.03,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,9.92,110,,343.528,fee schedule,110% of LA custom fee schedule,9.02,100,,343.528,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,58.52,38,,3.048,percent of total billed charges,38% of total billed charges,9.02,100,,430.08,Fee Schedule,100% of LA custom fee schedule,1820.94,3472,
"Protein Electro, Random Urine LC",4020553,CDM,301,RC,1-84156|2-,HCPCS,OUTPATIENT,,,181,108.6,,153.85,85,,123.08,Percent of total billed charges,85% of total billed charges,90.5,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90.5,50,,22.4,percent of total billed charges,50% of total billed charges,57.83,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,57.83,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.78,38,,3.048,percent of total billed charges,38% of total billed charges,72.4,40,,1.92,percent of total billed charges,40% of total billed charges,1821.94,3473,
COLLECTION: Venous Draw,4020559,CDM,300,RC,36415,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,10.16,136.6,,22.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.16,136.6,,36.4,fee schedule,136.60% of BCBS custom fee schedule,3.29,110,,2.56,fee schedule,110% of LA custom fee schedule,2.99,100,,2.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.048,percent of total billed charges,38% of total billed charges,2.99,100,,3.2,Fee Schedule,100% of LA custom fee schedule,1822.94,3474,
Bill Venipuncture,4020559,CDM,300,RC,36415,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,10.16,136.6,,36.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.16,136.6,,36.4,fee schedule,136.60% of BCBS custom fee schedule,3.29,110,,1.024,fee schedule,110% of LA custom fee schedule,2.99,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,4.56,38,,3.048,percent of total billed charges,38% of total billed charges,2.99,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1823.94,3475,
Blood Admin,4020560,CDM,391,RC,36430,HCPCS,OUTPATIENT,,,856,513.6,,727.6,85,,582.08,Percent of total billed charges,85% of total billed charges,911.71,136.6,,36.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,911.71,136.6,,29.6,fee schedule,136.60% of BCBS custom fee schedule,300.88,35.15,,34.248,fee schedule,35.15% of LA custom fee schedule,273.49,31.95,,34.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,150,100,,3.048,case rate,pays based on per visit rate,273.49,31.95,,42.88,Fee Schedule,31.95% of LA custom fee schedule,1824.94,3476,
Drug Screen Collection Fee,4020561,CDM,301,RC,H0048,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,29.6,percent of total billed charges,50% of total billed charges,9.59,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,71.744,percent of total billed charges,38% of total billed charges,12,40,,42.88,percent of total billed charges,40% of total billed charges,1825.94,3477,
Blood Processing and Storage,4020562,CDM,392,RC,P9016,HCPCS,OUTPATIENT,,,585,351,BL,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,378.48,136.6,,29.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,378.48,136.6,,29.6,fee schedule,136.60% of BCBS custom fee schedule,205.63,35.15,,34.248,percent of total billed charges,35.15% of total billed charges,101.28,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,14.288,case rate,pays based on per visit rate,186.91,31.95,,42.88,percent of total billed charges,31.95% of total billed charges,1826.94,3478,
ANCA Panel LC,4020564,CDM,302,RC,1-83520|2-,HCPCS,OUTPATIENT,,,422,253.2,,358.7,85,,286.96,Percent of total billed charges,85% of total billed charges,211,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,211,50,,29.6,percent of total billed charges,50% of total billed charges,134.83,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,134.83,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,160.36,38,,14.288,percent of total billed charges,38% of total billed charges,168.8,40,,42.88,percent of total billed charges,40% of total billed charges,1827.94,3479,
ANA Comprehensive Panel LC,4020565,CDM,302,RC,86225,HCPCS,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,64.08,136.6,,29.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,64.08,136.6,,380,fee schedule,136.60% of BCBS custom fee schedule,15.11,110,,34.248,fee schedule,110% of LA custom fee schedule,13.74,100,,34.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.72,38,,14.288,percent of total billed charges,38% of total billed charges,13.74,100,,42.88,Fee Schedule,100% of LA custom fee schedule,1828.94,3480,
"Extractable nuclear antigen, antibody to, any method",4020565,CDM,302,RC,86235,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,54.24,136.6,,380,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.24,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,34.248,fee schedule,110% of LA custom fee schedule,14.15,100,,34.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.1,38,,10.032,percent of total billed charges,38% of total billed charges,14.15,100,,42.88,Fee Schedule,100% of LA custom fee schedule,1829.94,3481,
.ENA+DNA/DS+Antich+Centro+FA...LC,4020565,CDM,302,RC,86225,HCPCS,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,64.08,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,64.08,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,15.11,110,,34.248,fee schedule,110% of LA custom fee schedule,13.74,100,,34.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.72,38,,14.288,percent of total billed charges,38% of total billed charges,13.74,100,,42.88,Fee Schedule,100% of LA custom fee schedule,1830.94,3482,
"Anticardiolip Ab, IgA/G/M, Qn LC",4020566,CDM,309,RC,86147,HCPCS,OUTPATIENT,,,174,104.4,,147.9,85,,118.32,Percent of total billed charges,85% of total billed charges,54.2,136.6,,23.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,190.8,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,34.248,fee schedule,110% of LA custom fee schedule,14.15,100,,34.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,66.12,38,,25.536,percent of total billed charges,38% of total billed charges,14.15,100,,42.88,Fee Schedule,100% of LA custom fee schedule,1831.94,3483,
"Anticardiolip Ab, IgA/G/M, Qn LC",4020566,CDM,309,RC,86147,HCPCS,OUTPATIENT,,,174,104.4,,147.9,85,,118.32,Percent of total billed charges,85% of total billed charges,54.2,136.6,,190.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.2,136.6,,1452,fee schedule,136.60% of BCBS custom fee schedule,15.57,110,,55.208,fee schedule,110% of LA custom fee schedule,14.15,100,,55.208,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,66.12,38,,369.36,percent of total billed charges,38% of total billed charges,14.15,100,,69.12,Fee Schedule,100% of LA custom fee schedule,1832.94,3484,
Celiac Disease Complete Panel LC,4020573,CDM,301,RC,82784,HCPCS,OUTPATIENT,,,380,228,,323,85,,258.4,Percent of total billed charges,85% of total billed charges,43.36,136.6,,1452,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.36,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,10.23,110,,55.208,fee schedule,110% of LA custom fee schedule,9.3,100,,55.208,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,144.4,38,,20.064,percent of total billed charges,38% of total billed charges,9.3,100,,69.12,Fee Schedule,100% of LA custom fee schedule,1833.94,3485,
Immunoassay for analyte other than infectious agent antibody,4020573,CDM,301,RC,83516,HCPCS,OUTPATIENT,,,79,47.4,,67.15,85,,53.72,Percent of total billed charges,85% of total billed charges,53.78,136.6,,58.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,53.78,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,12.68,110,,55.208,fee schedule,110% of LA custom fee schedule,11.53,100,,55.208,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,30.02,38,,14.288,percent of total billed charges,38% of total billed charges,11.53,100,,69.12,Fee Schedule,100% of LA custom fee schedule,1834.94,3486,
Environmental Culture LC,4020579,CDM,300,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,23.6,percent of total billed charges,50% of total billed charges,4.79,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,307.8,percent of total billed charges,38% of total billed charges,6,40,,69.12,percent of total billed charges,40% of total billed charges,1835.94,3487,
Lupus Anticoagulant Reflex LC,4020596,CDM,305,RC,85613,HCPCS,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,44.61,136.6,,23.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,44.61,136.6,,47.2,fee schedule,136.60% of BCBS custom fee schedule,10.54,110,,55.208,fee schedule,110% of LA custom fee schedule,9.58,100,,55.208,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,41.8,38,,2.368,percent of total billed charges,38% of total billed charges,9.58,100,,69.12,Fee Schedule,100% of LA custom fee schedule,1836.94,3488,
Measles/Mumps/Rubella Immunity LC,4020597,CDM,302,RC,86735,HCPCS,OUTPATIENT,,,275,165,,233.75,85,,187,Percent of total billed charges,85% of total billed charges,60.84,136.6,,47.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.84,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,14.36,110,,55.208,fee schedule,110% of LA custom fee schedule,13.05,100,,55.208,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,104.5,38,,2.52,percent of total billed charges,38% of total billed charges,13.05,100,,69.12,Fee Schedule,100% of LA custom fee schedule,1837.94,3489,
"Influenza AB, molecular, SJH",4020598,CDM,306,RC,87502,HCPCS,OUTPATIENT,,,348,208.8,,295.8,85,,236.64,Percent of total billed charges,85% of total billed charges,337.27,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,337.27,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,105.38,110,,14.568,fee schedule,110% of LA custom fee schedule,95.8,100,,14.568,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,132.24,38,,145.92,percent of total billed charges,38% of total billed charges,95.8,100,,18.24,Fee Schedule,100% of LA custom fee schedule,1838.94,3490,
"Immunoglobulin G, Qn, Serum LC",4020599,CDM,301,RC,82784,HCPCS,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,43.36,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.36,136.6,,280,fee schedule,136.60% of BCBS custom fee schedule,10.23,110,,14.568,fee schedule,110% of LA custom fee schedule,9.3,100,,14.568,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,20.14,38,,12.16,percent of total billed charges,38% of total billed charges,9.3,100,,18.24,Fee Schedule,100% of LA custom fee schedule,1839.94,3491,
Protein S-Antigen LC,4020602,CDM,305,RC,1-85305|2-,HCPCS,OUTPATIENT,,,258,154.8,,219.3,85,,175.44,Percent of total billed charges,85% of total billed charges,129,50,,280,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,129,50,,108,percent of total billed charges,50% of total billed charges,82.43,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,82.43,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,98.04,38,,24.32,percent of total billed charges,38% of total billed charges,103.2,40,,18.24,percent of total billed charges,40% of total billed charges,1840.94,3492,
PSA Screen,4020604,CDM,301,RC,G0103,HCPCS,OUTPATIENT,,,104,62.4,,88.4,85,,70.72,Percent of total billed charges,85% of total billed charges,85.76,136.6,,108,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,85.76,136.6,,100,fee schedule,136.60% of BCBS custom fee schedule,33.23,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,33.23,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.52,38,,5.168,percent of total billed charges,38% of total billed charges,41.6,40,,18.24,percent of total billed charges,40% of total billed charges,1841.94,3493,
"Erythropoietin (EPO), Serum LC",4020614,CDM,309,RC,82668,HCPCS,OUTPATIENT,,,128,76.8,,108.8,85,,87.04,Percent of total billed charges,85% of total billed charges,87.62,136.6,,100,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,87.62,136.6,,260,fee schedule,136.60% of BCBS custom fee schedule,20.67,110,,73.872,fee schedule,110% of LA custom fee schedule,18.79,100,,73.872,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,48.64,38,,0.608,percent of total billed charges,38% of total billed charges,18.79,100,,92.48,Fee Schedule,100% of LA custom fee schedule,1842.94,3494,
Serotonin LC,4020615,CDM,301,RC,84260,HCPCS,OUTPATIENT,,,211,126.6,,179.35,85,,143.48,Percent of total billed charges,85% of total billed charges,144.41,136.6,,260,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,144.41,136.6,,14,fee schedule,136.60% of BCBS custom fee schedule,34.08,110,,73.872,fee schedule,110% of LA custom fee schedule,30.98,100,,73.872,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80.18,38,,37.584,percent of total billed charges,38% of total billed charges,30.98,100,,92.48,Fee Schedule,100% of LA custom fee schedule,1843.94,3495,
Drug Screen FCS,4020615,CDM,300,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,16,percent of total billed charges,50% of total billed charges,7.99,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,17.312,percent of total billed charges,38% of total billed charges,10,40,,18.24,percent of total billed charges,40% of total billed charges,1844.94,3496,
NON ROUTINE LAB FEE,4020616,CDM,390,RC,,,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,87.5,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.5,50,,40,percent of total billed charges,50% of total billed charges,55.91,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150,100,,165.184,case rate,pays based on per visit rate,70,40,,18.24,percent of total billed charges,40% of total billed charges,1845.94,3497,
Iadna-dna/rna probe tq 6-11,4020617,CDM,300,RC,87506,HCPCS,OUTPATIENT,,,1453,871.8,,1235.05,85,,988.04,Percent of total billed charges,85% of total billed charges,818,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,818,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,289.29,110,,12.272,fee schedule,110% of LA custom fee schedule,262.99,100,,12.272,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,552.14,38,,5.472,percent of total billed charges,38% of total billed charges,262.99,100,,15.36,Fee Schedule,100% of LA custom fee schedule,1846.94,3498,
Reference Crossmatch,4020627,CDM,302,RC,86920,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,43.68,136.6,,46,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.68,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,56.52,110,,12.272,fee schedule,110% of LA custom fee schedule,51.38,100,,12.272,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.9,38,,26.752,percent of total billed charges,38% of total billed charges,51.38,100,,15.36,Fee Schedule,100% of LA custom fee schedule,1847.94,3499,
CANDIDA ANTIBODY,4020667,CDM,302,RC,86628,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.99,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.99,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,13.21,110,,1.28,fee schedule,110% of LA custom fee schedule,12.01,100,,1.28,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,26.752,percent of total billed charges,38% of total billed charges,12.01,100,,1.6,Fee Schedule,100% of LA custom fee schedule,1848.94,3500,
Bill West Nile Virus Ab,4020668,CDM,302,RC,86789,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,56.63,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.63,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,15.83,110,,4.816,fee schedule,110% of LA custom fee schedule,14.39,100,,4.816,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,37.24,38,,25.536,percent of total billed charges,38% of total billed charges,14.39,100,,6.024,Fee Schedule,100% of LA custom fee schedule,1849.94,3501,
"86789 West Nile Virus Antibody, CSF LC",4020668,CDM,302,RC,86789,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,56.63,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.63,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,15.83,110,,64.408,fee schedule,110% of LA custom fee schedule,14.39,100,,64.408,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,37.24,38,,25.536,percent of total billed charges,38% of total billed charges,14.39,100,,80.64,Fee Schedule,100% of LA custom fee schedule,1850.94,3502,
Bill Pretx Incubat w/chemicl,4020669,CDM,300,RC,86970,HCPCS,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,28.52,136.6,,6.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.52,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,3.04,110,,2.304,fee schedule,110% of LA custom fee schedule,2.76,100,,2.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,66.5,38,,8.896,percent of total billed charges,38% of total billed charges,2.76,100,,2.88,Fee Schedule,100% of LA custom fee schedule,1851.94,3503,
Bill RBC Pre-Treatment Serum,4020670,CDM,300,RC,86978,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,38.45,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,38.45,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,11.66,110,,2.304,fee schedule,110% of LA custom fee schedule,10.6,100,,2.304,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,28.5,38,,5.472,percent of total billed charges,38% of total billed charges,10.6,100,,2.88,Fee Schedule,100% of LA custom fee schedule,1852.94,3504,
Magnesium RBC,4020671,CDM,301,RC,83735,HCPCS,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,31.23,136.6,,6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,31.23,136.6,,240,fee schedule,136.60% of BCBS custom fee schedule,7.37,110,,5.112,fee schedule,110% of LA custom fee schedule,6.7,100,,5.112,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,42.56,38,,3.8,percent of total billed charges,38% of total billed charges,6.7,100,,6.4,Fee Schedule,100% of LA custom fee schedule,1853.94,3505,
LifeShare Absorption,4020672,CDM,309,RC,1-86970|2-,HCPCS,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,125,50,,240,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,125,50,,5,percent of total billed charges,50% of total billed charges,79.88,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,79.88,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,38,,9.864,percent of total billed charges,38% of total billed charges,100,40,,6.4,percent of total billed charges,40% of total billed charges,1854.94,3506,
West Nile AB CSF,4020673,CDM,302,RC,1-86789|2-,HCPCS,OUTPATIENT,,,280,168,,238,85,,190.4,Percent of total billed charges,85% of total billed charges,140,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,140,50,,57.6,percent of total billed charges,50% of total billed charges,89.46,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,89.46,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,106.4,38,,22.328,percent of total billed charges,38% of total billed charges,112,40,,7.36,percent of total billed charges,40% of total billed charges,1855.94,3507,
Tramadol Confirmation,4020674,CDM,300,RC,80373,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,27.52,136.6,,57.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.52,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,47.93,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,2.192,percent of total billed charges,38% of total billed charges,60,40,,7.36,percent of total billed charges,40% of total billed charges,1856.94,3508,
Reference ABO/Rh,4020675,CDM,302,RC,86900,HCPCS,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,13.91,136.6,,13.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,13.91,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,3.29,110,,204.48,fee schedule,110% of LA custom fee schedule,2.99,100,,204.48,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,6.46,38,,31.312,percent of total billed charges,38% of total billed charges,2.99,100,,256,Fee Schedule,100% of LA custom fee schedule,1857.94,3509,
Drug Screen Prsmptv 1 Class,4020676,CDM,300,RC,80307,HCPCS,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,223.2,136.6,,16,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,223.2,136.6,,196,fee schedule,136.60% of BCBS custom fee schedule,68.35,110,,50.096,fee schedule,110% of LA custom fee schedule,62.14,100,,50.096,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,74.1,38,,6.08,percent of total billed charges,38% of total billed charges,62.14,100,,62.72,Fee Schedule,100% of LA custom fee schedule,1858.94,3510,
FLUORESCENT ANTIBODY TITER,4020677,CDM,302,RC,1-86256|2-,HCPCS,OUTPATIENT,,,246,147.6,,209.1,85,,167.28,Percent of total billed charges,85% of total billed charges,123,50,,196,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,123,50,,8,percent of total billed charges,50% of total billed charges,78.6,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,78.6,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,93.48,38,,4.824,percent of total billed charges,38% of total billed charges,98.4,40,,8,percent of total billed charges,40% of total billed charges,1859.94,3511,
ASSAY OF SELENIUM,4020678,CDM,301,RC,84255,HCPCS,OUTPATIENT,,,174,104.4,,147.9,85,,118.32,Percent of total billed charges,85% of total billed charges,119.02,136.6,,8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,119.02,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,28.08,110,,6.392,fee schedule,110% of LA custom fee schedule,25.53,100,,6.392,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,66.12,38,,9.16,percent of total billed charges,38% of total billed charges,25.53,100,,8,Fee Schedule,100% of LA custom fee schedule,1860.94,3512,
REPTILASE TEST,4020679,CDM,305,RC,85635,HCPCS,OUTPATIENT,,,67,40.2,,56.95,85,,45.56,Percent of total billed charges,85% of total billed charges,45.9,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.9,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,10.84,110,,45.496,fee schedule,110% of LA custom fee schedule,9.85,100,,45.496,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.46,38,,9.16,percent of total billed charges,38% of total billed charges,9.85,100,,56.96,Fee Schedule,100% of LA custom fee schedule,1861.94,3513,
DRUG SCREEN QUANTITATIVE CAFFEINE,4020680,CDM,301,RC,80155,HCPCS,OUTPATIENT,,,97,58.2,,82.45,85,,65.96,Percent of total billed charges,85% of total billed charges,54.35,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,54.35,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,19.67,110,,0.768,fee schedule,110% of LA custom fee schedule,17.88,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.86,38,,9.16,percent of total billed charges,38% of total billed charges,17.88,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1862.94,3514,
RBC SICKLE CELL TEST,4020681,CDM,305,RC,85660,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,25.72,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.72,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,6.06,110,,1.024,fee schedule,110% of LA custom fee schedule,5.51,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,36.1,38,,9.16,percent of total billed charges,38% of total billed charges,5.51,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1863.94,3515,
Tryptase LC,4020682,CDM,302,RC,83520,HCPCS,OUTPATIENT,,,88,52.8,,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,60.38,136.6,,400,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.38,136.6,,96,fee schedule,136.60% of BCBS custom fee schedule,16.32,110,,1.024,fee schedule,110% of LA custom fee schedule,14.84,100,,1.024,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.44,38,,9.16,percent of total billed charges,38% of total billed charges,14.84,100,,1.28,Fee Schedule,100% of LA custom fee schedule,1864.94,3516,
Dexamethasone LC,4020683,CDM,301,RC,80299,HCPCS,OUTPATIENT,,,130,78,,110.5,85,,88.4,Percent of total billed charges,85% of total billed charges,63.85,136.6,,96,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.85,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,19.38,110,,7.16,fee schedule,110% of LA custom fee schedule,17.62,100,,7.16,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,49.4,38,,9.16,percent of total billed charges,38% of total billed charges,17.62,100,,8.96,Fee Schedule,100% of LA custom fee schedule,1865.94,3517,
"Immunofixation, Serum LC",4020684,CDM,300,RC,1-86334|2-,HCPCS,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,108,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108,50,,152,percent of total billed charges,50% of total billed charges,69.01,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.08,38,,9.16,percent of total billed charges,38% of total billed charges,86.4,40,,8.96,percent of total billed charges,40% of total billed charges,1866.94,3518,
"Drugs of Abuse Screen Only, Whole Blood LC",4020685,CDM,301,RC,80307,HCPCS,OUTPATIENT,,,399,239.4,,339.15,85,,271.32,Percent of total billed charges,85% of total billed charges,223.2,136.6,,152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,223.2,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,68.35,110,,10.688,fee schedule,110% of LA custom fee schedule,62.14,100,,10.688,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,151.62,38,,140.448,percent of total billed charges,38% of total billed charges,62.14,100,,13.384,Fee Schedule,100% of LA custom fee schedule,1867.94,3519,
HFE GENE,4020686,CDM,310,RC,81256,HCPCS,OUTPATIENT,,,445,267,,378.25,85,,302.6,Percent of total billed charges,85% of total billed charges,227.25,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,227.25,136.6,,152,fee schedule,136.60% of BCBS custom fee schedule,142.18,31.95,,113.488,percent of total billed charges,31.95% of total billed charges,142.18,31.95,,113.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,169.1,38,,1.264,percent of total billed charges,38% of total billed charges,178,40,,142.08,percent of total billed charges,40% of total billed charges,1868.94,3520,
Leukocyte Alkaline Phos Score LC,4020687,CDM,305,RC,85540,HCPCS,OUTPATIENT,,,59,35.4,,50.15,85,,40.12,Percent of total billed charges,85% of total billed charges,40.11,136.6,,152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.11,136.6,,158,fee schedule,136.60% of BCBS custom fee schedule,9.46,110,,113.488,fee schedule,110% of LA custom fee schedule,8.6,100,,113.488,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.42,38,,2.72,percent of total billed charges,38% of total billed charges,8.6,100,,142.08,Fee Schedule,100% of LA custom fee schedule,1869.94,3521,
Tetanus Antitoxoid Antibodies,4020693,CDM,302,RC,86317,HCPCS,OUTPATIENT,,,102,61.2,,86.7,85,,69.36,Percent of total billed charges,85% of total billed charges,69.91,136.6,,158,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.91,136.6,,150.8,fee schedule,136.60% of BCBS custom fee schedule,16.49,110,,11.248,fee schedule,110% of LA custom fee schedule,14.99,100,,11.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38.76,38,,108.584,percent of total billed charges,38% of total billed charges,14.99,100,,14.08,Fee Schedule,100% of LA custom fee schedule,1870.94,3522,
Pneumococcal Antibody Titer 23 serotype,4020694,CDM,302,RC,86317,HCPCS,OUTPATIENT,,,392,235.2,,333.2,85,,266.56,Percent of total billed charges,85% of total billed charges,69.91,136.6,,150.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.91,136.6,,164,fee schedule,136.60% of BCBS custom fee schedule,16.49,110,,11.248,fee schedule,110% of LA custom fee schedule,14.99,100,,11.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,148.96,38,,3.8,percent of total billed charges,38% of total billed charges,14.99,100,,14.08,Fee Schedule,100% of LA custom fee schedule,1871.94,3523,
India Ink Preparation LC,4020695,CDM,306,RC,87210,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,19.88,136.6,,164,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.88,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,6.05,110,,0.512,fee schedule,110% of LA custom fee schedule,5.5,100,,0.512,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.02,38,,7.6,percent of total billed charges,38% of total billed charges,5.5,100,,0.64,Fee Schedule,100% of LA custom fee schedule,1872.94,3524,
"Lead, Blood (Pediatric) LC",4020696,CDM,301,RC,83655,HCPCS,OUTPATIENT,,,83,49.8,,70.55,85,,56.44,Percent of total billed charges,85% of total billed charges,56.43,136.6,,5,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.43,136.6,,232,fee schedule,136.60% of BCBS custom fee schedule,13.32,110,,21.152,fee schedule,110% of LA custom fee schedule,12.11,100,,21.152,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.54,38,,25.768,percent of total billed charges,38% of total billed charges,12.11,100,,26.48,Fee Schedule,100% of LA custom fee schedule,1873.94,3525,
"Lactoferrin, Fecal, Quant. LC",4020697,CDM,301,RC,83631,HCPCS,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,77.22,136.6,,232,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.22,136.6,,232,fee schedule,136.60% of BCBS custom fee schedule,42.81,31.95,,8.912,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,8.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,1.832,percent of total billed charges,38% of total billed charges,53.6,40,,11.152,percent of total billed charges,40% of total billed charges,1874.94,3526,
Giardia/Cryptosporidium EIA LC,4020698,CDM,306,RC,87328,HCPCS,OUTPATIENT,,,82,49.2,,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,55.91,136.6,,232,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,15.2,110,,11.728,fee schedule,110% of LA custom fee schedule,13.82,100,,11.728,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,31.16,38,,39.128,percent of total billed charges,38% of total billed charges,13.82,100,,14.688,Fee Schedule,100% of LA custom fee schedule,1875.94,3527,
vW Antigen LC,4020699,CDM,305,RC,85240,HCPCS,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,83.49,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,83.49,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,19.69,110,,18.008,fee schedule,110% of LA custom fee schedule,17.9,100,,18.008,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,46.36,38,,51.072,percent of total billed charges,38% of total billed charges,17.9,100,,22.544,Fee Schedule,100% of LA custom fee schedule,1876.94,3528,
"Cytomegalovirus (CMV) Ab, IgM LC",4020700,CDM,302,RC,86645,HCPCS,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,78.56,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.56,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,18.54,110,,15.336,fee schedule,110% of LA custom fee schedule,16.85,100,,15.336,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,43.7,38,,2.392,percent of total billed charges,38% of total billed charges,16.85,100,,19.2,Fee Schedule,100% of LA custom fee schedule,1877.94,3529,
BRCAssure Comprehensive Test LC,4020702,CDM,300,RC,81162,HCPCS,OUTPATIENT,,,5200,3120,,4420,85,,3536,Percent of total billed charges,85% of total billed charges,7001.02,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7001.02,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,2007.37,110,,10.824,fee schedule,110% of LA custom fee schedule,1824.88,100,,10.824,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,1976,38,,54.568,percent of total billed charges,38% of total billed charges,1824.88,100,,13.552,Fee Schedule,100% of LA custom fee schedule,1878.94,3530,
"Bordetella Pertussis Ab, IgA,IgG,IgM LC",4020703,CDM,302,RC,86615,HCPCS,OUTPATIENT,,,162,97.2,,137.7,85,,110.16,Percent of total billed charges,85% of total billed charges,61.5,136.6,,12,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,61.5,136.6,,152,fee schedule,136.60% of BCBS custom fee schedule,14.51,110,,10.824,fee schedule,110% of LA custom fee schedule,13.19,100,,10.824,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,61.56,38,,12.96,percent of total billed charges,38% of total billed charges,13.19,100,,13.552,Fee Schedule,100% of LA custom fee schedule,1879.94,3531,
"Rocky Mtn Spotted Fev, IgG/IGM",4020704,CDM,302,RC,86757,HCPCS,OUTPATIENT,,,132,79.2,,112.2,85,,89.76,Percent of total billed charges,85% of total billed charges,90.27,136.6,,152,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,90.27,136.6,,57.6,fee schedule,136.60% of BCBS custom fee schedule,21.29,110,,15.712,fee schedule,110% of LA custom fee schedule,19.35,100,,15.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,50.16,38,,2.392,percent of total billed charges,38% of total billed charges,19.35,100,,19.672,Fee Schedule,100% of LA custom fee schedule,1880.94,3532,
Ehrlichia Ab Panel LC,4020705,CDM,302,RC,1-86666|4-,HCPCS,OUTPATIENT,,,277,166.2,,235.45,85,,188.36,Percent of total billed charges,85% of total billed charges,138.5,50,,57.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,138.5,50,,150,percent of total billed charges,50% of total billed charges,88.5,31.95,,10.304,percent of total billed charges,31.95% of total billed charges,88.5,31.95,,10.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,105.26,38,,1.824,percent of total billed charges,38% of total billed charges,110.8,40,,12.896,percent of total billed charges,40% of total billed charges,1881.94,3533,
Fecal Microsporidium LC,4020706,CDM,306,RC,1-87015|2-,HCPCS,OUTPATIENT,,,87,52.2,,73.95,85,,59.16,Percent of total billed charges,85% of total billed charges,43.5,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,43.5,50,,214,percent of total billed charges,50% of total billed charges,27.8,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,27.8,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.06,38,,127.68,percent of total billed charges,38% of total billed charges,34.8,40,,16.96,percent of total billed charges,40% of total billed charges,1882.94,3534,
Bartonella Antibody Panel LC,4020707,CDM,302,RC,1-86611|4-,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,214,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,296,percent of total billed charges,50% of total billed charges,22.37,31.95,,7.048,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,7.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.6,38,,89.552,percent of total billed charges,38% of total billed charges,28,40,,8.824,percent of total billed charges,40% of total billed charges,1883.94,3535,
"Toxoplasma gondii Ab, IgG, Qn LC",4020708,CDM,302,RC,86777,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,67.11,136.6,,296,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,67.11,136.6,,896,fee schedule,136.60% of BCBS custom fee schedule,15.19,110,,8.944,fee schedule,110% of LA custom fee schedule,13.81,100,,8.944,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,37.24,38,,48.264,percent of total billed charges,38% of total billed charges,13.81,100,,11.2,Fee Schedule,100% of LA custom fee schedule,1884.94,3536,
C DIFF AMPLIFIED PROBE,4020709,CDM,306,RC,87493,HCPCS,OUTPATIENT,,,239,143.4,,203.15,85,,162.52,Percent of total billed charges,85% of total billed charges,116.49,136.6,,896,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,116.49,136.6,,160,fee schedule,136.60% of BCBS custom fee schedule,41,110,,2.048,fee schedule,110% of LA custom fee schedule,37.27,100,,2.048,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,90.82,38,,3.8,percent of total billed charges,38% of total billed charges,37.27,100,,2.56,Fee Schedule,100% of LA custom fee schedule,1885.94,3537,
AFP Tetra LC,4020710,CDM,309,RC,1-82105|2-,HCPCS,OUTPATIENT,,,487,292.2,,413.95,85,,331.16,Percent of total billed charges,85% of total billed charges,243.5,50,,160,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,243.5,50,,18,percent of total billed charges,50% of total billed charges,155.6,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,155.6,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,185.06,38,,3.8,percent of total billed charges,38% of total billed charges,194.8,40,,22.4,percent of total billed charges,40% of total billed charges,1886.94,3538,
GAD-65 Auto Ab LC,4020714,CDM,302,RC,86341,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,92.27,136.6,,18,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,92.27,136.6,,174.8,fee schedule,136.60% of BCBS custom fee schedule,25.93,110,,56.488,fee schedule,110% of LA custom fee schedule,23.57,100,,56.488,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38,38,,36.376,percent of total billed charges,38% of total billed charges,23.57,100,,70.72,Fee Schedule,100% of LA custom fee schedule,1887.94,3539,
Islet Cell Anitbody,4020715,CDM,302,RC,86341,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,92.27,136.6,,174.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,92.27,136.6,,155.2,fee schedule,136.60% of BCBS custom fee schedule,25.93,110,,17.256,fee schedule,110% of LA custom fee schedule,23.57,100,,17.256,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38,38,,2.176,percent of total billed charges,38% of total billed charges,23.57,100,,21.6,Fee Schedule,100% of LA custom fee schedule,1888.94,3540,
"IA-2, Autoantibodies LC",4020715,CDM,302,RC,86341,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,92.27,136.6,,155.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,92.27,136.6,,364,fee schedule,136.60% of BCBS custom fee schedule,25.93,110,,0.768,fee schedule,110% of LA custom fee schedule,23.57,100,,0.768,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38,38,,171.76,percent of total billed charges,38% of total billed charges,23.57,100,,0.96,Fee Schedule,100% of LA custom fee schedule,1889.94,3541,
IA2 Autoantibodies LC,4020715,CDM,302,RC,86341,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,92.27,136.6,,364,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,92.27,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,25.93,110,,11.504,fee schedule,110% of LA custom fee schedule,23.57,100,,11.504,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,38,38,,226.48,percent of total billed charges,38% of total billed charges,23.57,100,,14.4,Fee Schedule,100% of LA custom fee schedule,1890.94,3542,
D002-IgE D Farinae Mite LC,4020720,CDM,300,RC,86003,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,24.34,136.6,,10.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.34,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,5.74,110,,4.472,fee schedule,110% of LA custom fee schedule,5.22,100,,4.472,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.68,38,,14.896,percent of total billed charges,38% of total billed charges,5.22,100,,5.6,Fee Schedule,100% of LA custom fee schedule,1891.94,3543,
T pallidum Ab (FTA-Ab) LC,4020721,CDM,302,RC,86780,HCPCS,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,43.96,136.6,,84,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.96,136.6,,140,fee schedule,136.60% of BCBS custom fee schedule,14.56,110,,15.336,fee schedule,110% of LA custom fee schedule,13.24,100,,15.336,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,34.58,38,,24.016,percent of total billed charges,38% of total billed charges,13.24,100,,19.2,Fee Schedule,100% of LA custom fee schedule,1892.94,3544,
Nephelometry,4020722,CDM,301,RC,83883,HCPCS,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,21.68,136.6,,140,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.68,136.6,,140,fee schedule,136.60% of BCBS custom fee schedule,6.25,110,,50.096,fee schedule,110% of LA custom fee schedule,5.68,100,,50.096,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.34,38,,186.96,percent of total billed charges,38% of total billed charges,5.68,100,,62.72,Fee Schedule,100% of LA custom fee schedule,1893.94,3545,
"Nephelometry, each analyte not elsewhere specified",4020722,CDM,301,RC,83883,HCPCS,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,21.68,136.6,,140,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.68,136.6,,135.2,fee schedule,136.60% of BCBS custom fee schedule,6.25,110,,11.248,fee schedule,110% of LA custom fee schedule,5.68,100,,11.248,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.34,38,,288.8,percent of total billed charges,38% of total billed charges,5.68,100,,14.08,Fee Schedule,100% of LA custom fee schedule,1894.94,3546,
"83883 Nephelometry, each analyte not elsewhere specified",4020722,CDM,301,RC,83883,HCPCS,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,21.68,136.6,,135.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.68,136.6,,136,fee schedule,136.60% of BCBS custom fee schedule,6.25,110,,3.576,fee schedule,110% of LA custom fee schedule,5.68,100,,3.576,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,35.34,38,,8.816,percent of total billed charges,38% of total billed charges,5.68,100,,4.48,Fee Schedule,100% of LA custom fee schedule,1895.94,3547,
"Saccharomyces cerevisiae, IgA LC",4020723,CDM,302,RC,86671,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,57.17,136.6,,136,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.17,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,13.48,110,,23.624,fee schedule,110% of LA custom fee schedule,12.25,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,46.512,percent of total billed charges,38% of total billed charges,12.25,100,,21.472,Fee Schedule,100% of LA custom fee schedule,1896.94,3548,
"Saccharomyces cerevisiae, IgG LC",4020723,CDM,302,RC,86671,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,57.17,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.17,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,13.48,110,,544.432,fee schedule,110% of LA custom fee schedule,12.25,100,,544.432,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,0.912,percent of total billed charges,38% of total billed charges,12.25,100,,681.6,Fee Schedule,100% of LA custom fee schedule,1897.94,3549,
Atypical pANCA LC,4020723,CDM,302,RC,86256,HCPCS,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,56.2,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.2,136.6,,366,fee schedule,136.60% of BCBS custom fee schedule,13.26,110,,9.456,fee schedule,110% of LA custom fee schedule,12.05,100,,9.456,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,25.84,38,,43.168,percent of total billed charges,38% of total billed charges,12.05,100,,11.84,Fee Schedule,100% of LA custom fee schedule,1898.94,3550,
"Amphetamine Confirmation, Ur LC",4020724,CDM,301,RC,80324,HCPCS,OUTPATIENT,,,190,114,,161.5,85,,129.2,Percent of total billed charges,85% of total billed charges,21.71,136.6,,366,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,21.71,136.6,,188,fee schedule,136.60% of BCBS custom fee schedule,60.71,31.95,,560.36,percent of total billed charges,31.95% of total billed charges,60.71,31.95,,560.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,72.2,38,,48.336,percent of total billed charges,38% of total billed charges,76,40,,701.544,percent of total billed charges,40% of total billed charges,1899.94,3551,
SMEAR FLUORESCENT/ACID STAI,4020725,CDM,306,RC,87206,HCPCS,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,25.03,136.6,,188,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,25.03,136.6,,424,fee schedule,136.60% of BCBS custom fee schedule,5.93,110,,280.176,fee schedule,110% of LA custom fee schedule,5.39,100,,280.176,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.54,38,,6.08,percent of total billed charges,38% of total billed charges,5.39,100,,350.768,Fee Schedule,100% of LA custom fee schedule,1900.94,3552,
Procalcitonin LC,4020726,CDM,301,RC,84145,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,64.32,136.6,,424,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,64.32,136.6,,411.6,fee schedule,136.60% of BCBS custom fee schedule,28.13,110,,108.112,fee schedule,110% of LA custom fee schedule,25.57,100,,108.112,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,2.736,percent of total billed charges,38% of total billed charges,25.57,100,,135.344,Fee Schedule,100% of LA custom fee schedule,1901.94,3553,
Chylmd pneum dna amp probe,4020728,CDM,306,RC,87486,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,411.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,164.4,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,38.208,fee schedule,110% of LA custom fee schedule,35.09,100,,38.208,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,130.72,percent of total billed charges,38% of total billed charges,35.09,100,,47.84,Fee Schedule,100% of LA custom fee schedule,1902.94,3554,
Chylmd pneum dna amp probe,4020728,CDM,306,RC,87486,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,164.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,106.8,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,103.064,fee schedule,110% of LA custom fee schedule,35.09,100,,103.064,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,130.72,percent of total billed charges,38% of total billed charges,35.09,100,,129.032,Fee Schedule,100% of LA custom fee schedule,1903.94,3555,
Chlamydia pneumoniae -BioFire,4020728,CDM,306,RC,87486,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,106.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,162.4,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,32.12,fee schedule,110% of LA custom fee schedule,35.09,100,,32.12,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,29.792,percent of total billed charges,38% of total billed charges,35.09,100,,40.216,Fee Schedule,100% of LA custom fee schedule,1904.94,3556,
M.pneumon dna amp probe,4020729,CDM,306,RC,87581,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,162.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,168.8,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,30.224,fee schedule,110% of LA custom fee schedule,35.09,100,,30.224,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,130.72,percent of total billed charges,38% of total billed charges,35.09,100,,37.84,Fee Schedule,100% of LA custom fee schedule,1905.94,3557,
M.pneumon dna amp probe,4020729,CDM,306,RC,87581,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,168.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,505.2,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,31.712,fee schedule,110% of LA custom fee schedule,35.09,100,,31.712,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,13.984,percent of total billed charges,38% of total billed charges,35.09,100,,39.704,Fee Schedule,100% of LA custom fee schedule,1906.94,3558,
Mycoplasma pneumoniae -BioFire,4020729,CDM,306,RC,87581,HCPCS,OUTPATIENT,,,136.5,81.9,,116.03,85,,92.824,Percent of total billed charges,85% of total billed charges,163.65,136.6,,505.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,178.8,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,45.176,fee schedule,110% of LA custom fee schedule,35.09,100,,45.176,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.87,38,,8.072,percent of total billed charges,38% of total billed charges,35.09,100,,56.552,Fee Schedule,100% of LA custom fee schedule,1907.94,3559,
EBV Antibody Profile LC,4020730,CDM,302,RC,1-86664|2-,HCPCS,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,178.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,367.2,percent of total billed charges,50% of total billed charges,67.1,31.95,,47.624,percent of total billed charges,31.95% of total billed charges,67.1,31.95,,47.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.8,38,,279.072,percent of total billed charges,38% of total billed charges,84,40,,59.616,percent of total billed charges,40% of total billed charges,1908.94,3560,
"Strep A, molecular",4020731,CDM,306,RC,87651,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,163.65,136.6,,367.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,163.65,136.6,,164.4,fee schedule,136.60% of BCBS custom fee schedule,38.6,110,,38.2,fee schedule,110% of LA custom fee schedule,35.09,100,,38.2,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,76,38,,130.72,percent of total billed charges,38% of total billed charges,35.09,100,,47.824,Fee Schedule,100% of LA custom fee schedule,1909.94,3561,
Respiratory Virus 12-25 targets,4020735,CDM,306,RC,87633,HCPCS,OUTPATIENT,,,926,555.6,,787.1,85,,629.68,Percent of total billed charges,85% of total billed charges,1613.52,136.6,,164.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1613.52,136.6,,522.4,fee schedule,136.60% of BCBS custom fee schedule,295.86,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,295.86,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,351.88,38,,14.288,percent of total billed charges,38% of total billed charges,370.4,40,,53.6,percent of total billed charges,40% of total billed charges,1910.94,3562,
COVID 19 TESTING NON CDC,4020736,CDM,300,RC,U0002,HCPCS,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,105.18,136.6,,522.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,105.18,136.6,,202.8,fee schedule,136.60% of BCBS custom fee schedule,36.74,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.7,38,,0.608,percent of total billed charges,38% of total billed charges,46,40,,53.6,percent of total billed charges,40% of total billed charges,1911.94,3563,
Specimen handling office-lab,4020738,CDM,300,RC,99000,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,202.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,199.6,percent of total billed charges,50% of total billed charges,7.99,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,0.608,percent of total billed charges,38% of total billed charges,10,40,,41.088,percent of total billed charges,40% of total billed charges,1912.94,3564,
Specimen handling pt-lab,4020739,CDM,300,RC,99001,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,199.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,150,percent of total billed charges,50% of total billed charges,7.99,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,13.376,percent of total billed charges,38% of total billed charges,10,40,,41.088,percent of total billed charges,40% of total billed charges,1913.94,3565,
"SARS-CoV-2 (COVID-19) Antibody, IgG LC",4020741,CDM,300,RC,86769,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,57.55,136.6,,150,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.55,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,34.76,110,,17.904,fee schedule,110% of LA custom fee schedule,31.6,100,,17.904,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,13.376,percent of total billed charges,38% of total billed charges,31.6,100,,22.416,Fee Schedule,100% of LA custom fee schedule,1914.94,3566,
"SARS-CoV-2 (COVID-19) Antibody, IgM LC",4020741,CDM,300,RC,86769,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,57.55,136.6,,36,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.55,136.6,,170,fee schedule,136.60% of BCBS custom fee schedule,34.76,110,,49.2,fee schedule,110% of LA custom fee schedule,31.6,100,,49.2,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,8.816,percent of total billed charges,38% of total billed charges,31.6,100,,61.592,Fee Schedule,100% of LA custom fee schedule,1915.94,3567,
"SARS-CoV-2 (COVID-19) Antibody, IgA LC",4020741,CDM,300,RC,86769,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,57.55,136.6,,170,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.55,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,34.76,110,,24.088,fee schedule,110% of LA custom fee schedule,31.6,100,,24.088,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,57,38,,0.304,percent of total billed charges,38% of total billed charges,31.6,100,,30.16,Fee Schedule,100% of LA custom fee schedule,1916.94,3568,
SARS-CoV-2 (COVID-19) IgG Antibodies(No Ratio),4020741,CDM,300,RC,86769,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,57.55,136.6,,218,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.55,136.6,,244,fee schedule,136.60% of BCBS custom fee schedule,34.76,110,,24.56,fee schedule,110% of LA custom fee schedule,31.6,100,,24.56,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,63.84,38,,130.72,percent of total billed charges,38% of total billed charges,31.6,100,,30.752,Fee Schedule,100% of LA custom fee schedule,1917.94,3569,
"Nicotine and Metabolite, Quant LC",4020745,CDM,301,RC,80323,HCPCS,OUTPATIENT,,,40,24,,,,,,other,Not separately reimbursable,33.13,136.6,,244,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,33.13,136.6,,45.6,fee schedule,136.60% of BCBS custom fee schedule,12.78,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,130.72,percent of total billed charges,38% of total billed charges,16,40,,53.6,percent of total billed charges,40% of total billed charges,1918.94,3570,
Biofire GI panel PCR,4020749,CDM,310,RC,87507,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,1597.36,136.6,,45.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1597.36,136.6,,213.6,fee schedule,136.60% of BCBS custom fee schedule,458.46,110,,146.424,fee schedule,110% of LA custom fee schedule,416.78,100,,146.424,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,266,38,,63.84,percent of total billed charges,38% of total billed charges,416.78,100,,183.32,Fee Schedule,100% of LA custom fee schedule,1919.94,3571,
SARS-CoV-2 (COVID-19) RNA (ID Now),4020800,CDM,300,RC,87635,HCPCS,OUTPATIENT,,,154,92.4,,,,,,other,Not separately reimbursable,105.18,136.6,,213.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,105.18,136.6,,159.2,fee schedule,136.60% of BCBS custom fee schedule,42.33,110,,146.424,fee schedule,110% of LA custom fee schedule,38.48,100,,146.424,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,58.52,38,,750.88,percent of total billed charges,38% of total billed charges,38.48,100,,183.32,Fee Schedule,100% of LA custom fee schedule,1920.94,3572,
Drug Screening Ketamine and Norketamine,4020857,CDM,301,RC,80357,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,27.52,136.6,,159.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.52,136.6,,233.6,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,3.544,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,3.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,295.488,percent of total billed charges,38% of total billed charges,20,40,,4.44,percent of total billed charges,40% of total billed charges,1921.94,3573,
Drug Screening Methadone,4020858,CDM,301,RC,80358,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,22.84,136.6,,233.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,22.84,136.6,,191.6,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,237.12,percent of total billed charges,38% of total billed charges,20,40,,5.68,percent of total billed charges,40% of total billed charges,1922.94,3574,
MOPATH PROCEDURE LEVEL 9,4030000,CDM,310,RC,81408,HCPCS,OUTPATIENT,,,465,279,,,,,,other,Not separately reimbursable,5632.67,136.6,,191.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5632.67,136.6,,175.2,fee schedule,136.60% of BCBS custom fee schedule,148.57,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,148.57,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,176.7,38,,130.72,percent of total billed charges,38% of total billed charges,186,40,,6.4,percent of total billed charges,40% of total billed charges,1923.94,3575,
BARD1,4030001,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,175.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,158,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,130.72,percent of total billed charges,38% of total billed charges,200,40,,4.496,percent of total billed charges,40% of total billed charges,1924.94,3576,
BRCA1 GENE KNOWN FAM VARIANT,4030003,CDM,310,RC,81215,HCPCS,OUTPATIENT,,,465,279,,,,,,other,Not separately reimbursable,232.5,50,,158,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,232.5,50,,244.8,percent of total billed charges,50% of total billed charges,99.23,110,,3.232,fee schedule,110% of LA custom fee schedule,90.21,100,,3.232,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,176.7,38,,644.48,percent of total billed charges,38% of total billed charges,90.21,100,,4.048,Fee Schedule,100% of LA custom fee schedule,1925.94,3577,
BRCA2 GENE FULL SEQUENCE,4030004,CDM,310,RC,81216,HCPCS,OUTPATIENT,,,10000,6000,,,,,,other,Not separately reimbursable,5000,50,,244.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5000,50,,10,percent of total billed charges,50% of total billed charges,99.23,110,,9.6,fee schedule,110% of LA custom fee schedule,90.21,100,,9.6,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,3800,38,,40.128,percent of total billed charges,38% of total billed charges,90.21,100,,12.024,Fee Schedule,100% of LA custom fee schedule,1926.94,3578,
BRCA2 GENE KNOWN FAM VARIANT,4030005,CDM,310,RC,81217,HCPCS,OUTPATIENT,,,465,279,,,,,,other,Not separately reimbursable,232.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,232.5,50,,92,percent of total billed charges,50% of total billed charges,99.23,110,,3.68,fee schedule,110% of LA custom fee schedule,90.21,100,,3.68,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,176.7,38,,113.088,percent of total billed charges,38% of total billed charges,90.21,100,,4.608,Fee Schedule,100% of LA custom fee schedule,1927.94,3579,
BRCA1&2 185&5385&6174 VAR,4030008,CDM,310,RC,81212,HCPCS,OUTPATIENT,,,881,528.6,,,,,,other,Not separately reimbursable,440.5,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,440.5,50,,34,percent of total billed charges,50% of total billed charges,188.01,110,,1.88,fee schedule,110% of LA custom fee schedule,170.92,100,,1.88,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,334.78,38,,113.088,percent of total billed charges,38% of total billed charges,170.92,100,,2.352,Fee Schedule,100% of LA custom fee schedule,1928.94,3580,
BRCA1&2 UNCOM DUP/DEL VAR,4030009,CDM,310,RC,81164,HCPCS,OUTPATIENT,,,2906,1743.6,,,,,,other,Not separately reimbursable,1645.39,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1645.39,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,497.41,110,,25.312,fee schedule,110% of LA custom fee schedule,452.19,100,,10.776,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,1104.28,38,,113.088,percent of total billed charges,38% of total billed charges,452.19,100,,23.008,Fee Schedule,100% of LA custom fee schedule,1929.94,3581,
BRIP1,4030010,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,23.6,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,315.24,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,315.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,113.088,percent of total billed charges,38% of total billed charges,200,40,,394.664,percent of total billed charges,40% of total billed charges,1930.94,3582,
MOPATH PROCEDURE LEVEL 7,4030011,CDM,310,RC,81406,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,796.69,136.6,,23.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.69,136.6,,35.2,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,113.088,percent of total billed charges,38% of total billed charges,200,40,,0.456,percent of total billed charges,40% of total billed charges,1931.94,3583,
CHEK2,4030012,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,35.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,60.8,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,40.128,percent of total billed charges,38% of total billed charges,200,40,,0.456,percent of total billed charges,40% of total billed charges,1932.94,3584,
Molecular Pathology Procedure Unlisted,4030013,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,60.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,116,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,113.088,percent of total billed charges,38% of total billed charges,200,40,,320,percent of total billed charges,40% of total billed charges,1933.94,3585,
MLH1 gene,4030014,CDM,310,RC,81288,HCPCS,OUTPATIENT,,,798,478.8,,,,,,other,Not separately reimbursable,399,50,,116,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,399,50,,80,percent of total billed charges,50% of total billed charges,254.96,31.95,,26.36,percent of total billed charges,31.95% of total billed charges,254.96,31.95,,26.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,303.24,38,,113.088,percent of total billed charges,38% of total billed charges,319.2,40,,33,percent of total billed charges,40% of total billed charges,1934.94,3586,
MLH1 GENE FULL SEQ,4030015,CDM,310,RC,81292,HCPCS,OUTPATIENT,,,3223,1933.8,,,,,,other,Not separately reimbursable,1902.16,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1902.16,136.6,,6.088,fee schedule,136.60% of BCBS custom fee schedule,1029.75,31.95,,5.536,percent of total billed charges,31.95% of total billed charges,1029.75,31.95,,5.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1224.74,38,,420.432,percent of total billed charges,38% of total billed charges,1289.2,40,,6.936,percent of total billed charges,40% of total billed charges,1935.94,3587,
MLH1 GENE KNOWN VARIANTS,4030016,CDM,310,RC,81293,HCPCS,OUTPATIENT,,,1292,775.2,,,,,,other,Not separately reimbursable,646,50,,6.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,646,50,,65.2,percent of total billed charges,50% of total billed charges,412.79,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,412.79,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,490.96,38,,9.12,percent of total billed charges,38% of total billed charges,516.8,40,,13.12,percent of total billed charges,40% of total billed charges,1936.94,3588,
MLH1 GENE DUP/DELETE VARIANT,4030017,CDM,310,RC,81294,HCPCS,OUTPATIENT,,,951,570.6,,,,,,other,Not separately reimbursable,475.5,50,,65.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,475.5,50,,130,percent of total billed charges,50% of total billed charges,303.84,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,303.84,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,361.38,38,,7.6,percent of total billed charges,38% of total billed charges,380.4,40,,13.12,percent of total billed charges,40% of total billed charges,1937.94,3589,
MRE11A,4030018,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,130,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,102.8,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,45.6,percent of total billed charges,38% of total billed charges,200,40,,4.6,percent of total billed charges,40% of total billed charges,1938.94,3590,
MSH2 GENE FULL SEQ,4030019,CDM,310,RC,81295,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,1075,136.6,,102.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1075,136.6,,128.8,fee schedule,136.60% of BCBS custom fee schedule,319.5,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,319.5,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,36.48,percent of total billed charges,38% of total billed charges,400,40,,4.6,percent of total billed charges,40% of total billed charges,1939.94,3591,
MSH2 GENE KNOWN VARIANTS,4030020,CDM,310,RC,81296,HCPCS,OUTPATIENT,,,646,387.6,,,,,,other,Not separately reimbursable,323,50,,128.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,323,50,,40,percent of total billed charges,50% of total billed charges,206.4,31.95,,4.136,percent of total billed charges,31.95% of total billed charges,206.4,31.95,,4.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,245.48,38,,36.48,percent of total billed charges,38% of total billed charges,258.4,40,,5.176,percent of total billed charges,40% of total billed charges,1940.94,3592,
MSH2 GENE DUP/DELETE VARIANT,4030021,CDM,310,RC,81297,HCPCS,OUTPATIENT,,,757,454.2,,,,,,other,Not separately reimbursable,378.5,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,378.5,50,,93.6,percent of total billed charges,50% of total billed charges,241.86,31.95,,3.232,percent of total billed charges,31.95% of total billed charges,241.86,31.95,,3.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,287.66,38,,5.472,percent of total billed charges,38% of total billed charges,302.8,40,,4.048,percent of total billed charges,40% of total billed charges,1941.94,3593,
MSH6 GENE FULL SEQ,4030022,CDM,310,RC,81298,HCPCS,OUTPATIENT,,,1436,861.6,,,,,,other,Not separately reimbursable,718,50,,93.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,718,50,,40,percent of total billed charges,50% of total billed charges,458.8,31.95,,3.408,percent of total billed charges,31.95% of total billed charges,458.8,31.95,,3.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,545.68,38,,25.84,percent of total billed charges,38% of total billed charges,574.4,40,,4.264,percent of total billed charges,40% of total billed charges,1942.94,3594,
MSH6 GENE KNOWN VARIANTS,4030023,CDM,310,RC,81299,HCPCS,OUTPATIENT,,,804,482.4,,,,,,other,Not separately reimbursable,867.44,136.6,,40,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,867.44,136.6,,64.4,fee schedule,136.60% of BCBS custom fee schedule,256.88,31.95,,4.44,percent of total billed charges,31.95% of total billed charges,256.88,31.95,,4.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,305.52,38,,40.76,percent of total billed charges,38% of total billed charges,321.6,40,,5.56,percent of total billed charges,40% of total billed charges,1943.94,3595,
MSH6 GENE DUP/DELETE VARIANT,4030024,CDM,310,RC,81300,HCPCS,OUTPATIENT,,,806,483.6,,,,,,other,Not separately reimbursable,403,50,,64.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,403,50,,77.2,percent of total billed charges,50% of total billed charges,257.52,31.95,,5.232,percent of total billed charges,31.95% of total billed charges,257.52,31.95,,5.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,306.28,38,,5.472,percent of total billed charges,38% of total billed charges,322.4,40,,6.544,percent of total billed charges,40% of total billed charges,1944.94,3596,
NBN,4030025,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,77.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,281.16,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,281.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,8.512,percent of total billed charges,38% of total billed charges,200,40,,352,percent of total billed charges,40% of total billed charges,1945.94,3597,
PMS2 GENE FULL SEQ ANALYSIS,4030027,CDM,310,RC,81317,HCPCS,OUTPATIENT,,,3897,2338.2,,,,,,other,Not separately reimbursable,1948.5,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1948.5,50,,60.8,percent of total billed charges,50% of total billed charges,1245.09,31.95,,0.736,percent of total billed charges,31.95% of total billed charges,1245.09,31.95,,0.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1480.86,38,,41.04,percent of total billed charges,38% of total billed charges,1558.8,40,,0.92,percent of total billed charges,40% of total billed charges,1946.94,3598,
PMS2 KNOWN FAMILIAL VARIANTS,4030028,CDM,310,RC,81318,HCPCS,OUTPATIENT,,,921,552.6,,,,,,other,Not separately reimbursable,460.5,50,,60.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,460.5,50,,4,percent of total billed charges,50% of total billed charges,294.26,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,294.26,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,349.98,38,,1.824,percent of total billed charges,38% of total billed charges,368.4,40,,1.296,percent of total billed charges,40% of total billed charges,1947.94,3599,
PMS2 GENE DUP/DELET VARIANTS,4030029,CDM,310,RC,81319,HCPCS,OUTPATIENT,,,1106,663.6,,,,,,other,Not separately reimbursable,553,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,553,50,,82.4,percent of total billed charges,50% of total billed charges,353.37,31.95,,3.008,percent of total billed charges,31.95% of total billed charges,353.37,31.95,,3.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,420.28,38,,130.72,percent of total billed charges,38% of total billed charges,442.4,40,,3.76,percent of total billed charges,40% of total billed charges,1948.94,3600,
PTEN GENE FULL SEQUENCE,4030030,CDM,310,RC,81321,HCPCS,OUTPATIENT,,,2996,1797.6,,,,,,other,Not separately reimbursable,1689.81,136.6,,82.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1689.81,136.6,,115.2,fee schedule,136.60% of BCBS custom fee schedule,957.22,31.95,,72.848,percent of total billed charges,31.95% of total billed charges,957.22,31.95,,72.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1138.48,38,,130.72,percent of total billed charges,38% of total billed charges,1198.4,40,,91.2,percent of total billed charges,40% of total billed charges,1949.94,3601,
PTEN GENE KNOWN FAM VARIANT,4030031,CDM,310,RC,81322,HCPCS,OUTPATIENT,,,291,174.6,,,,,,other,Not separately reimbursable,145.5,50,,115.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,145.5,50,,226.4,percent of total billed charges,50% of total billed charges,92.97,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,92.97,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.58,38,,130.72,percent of total billed charges,38% of total billed charges,116.4,40,,9.6,percent of total billed charges,40% of total billed charges,1950.94,3602,
PTEN GENE DUP/DELET VARIANT,4030032,CDM,310,RC,81323,HCPCS,OUTPATIENT,,,437,262.2,,,,,,other,Not separately reimbursable,844.9,136.6,,226.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,844.9,136.6,,144,fee schedule,136.60% of BCBS custom fee schedule,139.62,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,139.62,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,166.06,38,,35.024,percent of total billed charges,38% of total billed charges,174.8,40,,0.64,percent of total billed charges,40% of total billed charges,1951.94,3603,
RAD50,4030033,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,144,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,80.4,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,2.4,percent of total billed charges,38% of total billed charges,200,40,,96,percent of total billed charges,40% of total billed charges,1952.94,3604,
RAD51C,4030034,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,80.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,304.168,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,304.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,113.088,percent of total billed charges,38% of total billed charges,200,40,,380.8,percent of total billed charges,40% of total billed charges,1953.94,3605,
RAD51D,4030035,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,60.8,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,472.864,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,472.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,113.088,percent of total billed charges,38% of total billed charges,200,40,,592,percent of total billed charges,40% of total billed charges,1954.94,3606,
RINT1,4030036,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,60.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,393.624,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,393.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,237.12,percent of total billed charges,38% of total billed charges,200,40,,492.8,percent of total billed charges,40% of total billed charges,1955.94,3607,
MOPATH PROCEDURE LEVEL 5,4030037,CDM,310,RC,81404,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,774.02,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,774.02,136.6,,76,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,85.112,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,85.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,4.104,percent of total billed charges,38% of total billed charges,200,40,,106.56,percent of total billed charges,40% of total billed charges,1956.94,3608,
MOPATH PROCEDURE LEVEL 6,4030038,CDM,310,RC,81405,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,848.7,136.6,,76,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,848.7,136.6,,60.8,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,411.52,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,411.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,6.92,percent of total billed charges,38% of total billed charges,200,40,,515.2,percent of total billed charges,40% of total billed charges,1957.94,3609,
XRCC2,4030039,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,60.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,10.032,percent of total billed charges,38% of total billed charges,200,40,,1.6,percent of total billed charges,40% of total billed charges,1958.94,3610,
CYP2C19 GENE COM VARIANTS,4030040,CDM,310,RC,81225,HCPCS,OUTPATIENT,,,1455,873,,,,,,other,Not separately reimbursable,820.57,136.6,,55.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,820.57,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,464.87,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,464.87,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,552.9,38,,1.368,percent of total billed charges,38% of total billed charges,582,40,,3.2,percent of total billed charges,40% of total billed charges,1959.94,3611,
CYP2D6 GENE COM VARIANTS,4030041,CDM,310,RC,81226,HCPCS,OUTPATIENT,,,2252,1351.2,,,,,,other,Not separately reimbursable,1269.92,136.6,,60,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1269.92,136.6,,26.4,fee schedule,136.60% of BCBS custom fee schedule,719.51,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,719.51,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,855.76,38,,10.336,percent of total billed charges,38% of total billed charges,900.8,40,,8,percent of total billed charges,40% of total billed charges,1960.94,3612,
CYP2C9 GENE COM VARIANTS,4030042,CDM,310,RC,81227,HCPCS,OUTPATIENT,,,873,523.8,,,,,,other,Not separately reimbursable,492.32,136.6,,26.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,492.32,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,278.92,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,278.92,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,331.74,38,,4.56,percent of total billed charges,38% of total billed charges,349.2,40,,17.6,percent of total billed charges,40% of total billed charges,1961.94,3613,
F2 GENE,4030043,CDM,310,RC,81240,HCPCS,OUTPATIENT,,,335,201,,,,,,other,Not separately reimbursable,185.01,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,185.01,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,107.03,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,107.03,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.3,38,,13.68,percent of total billed charges,38% of total billed charges,134,40,,2.24,percent of total billed charges,40% of total billed charges,1962.94,3614,
F5 GENE,4030044,CDM,310,RC,81241,HCPCS,OUTPATIENT,,,416,249.6,,,,,,other,Not separately reimbursable,212.47,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.47,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,60.53,110,,5.368,fee schedule,110% of LA custom fee schedule,55.03,100,,5.368,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,158.08,38,,28.272,percent of total billed charges,38% of total billed charges,55.03,100,,6.72,Fee Schedule,100% of LA custom fee schedule,1963.94,3615,
MTHFR GENE,4030045,CDM,310,RC,81291,HCPCS,OUTPATIENT,,,297,178.2,,,,,,other,Not separately reimbursable,184.03,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,184.03,136.6,,32,fee schedule,136.60% of BCBS custom fee schedule,94.89,31.95,,3.6,percent of total billed charges,31.95% of total billed charges,94.89,31.95,,3.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,112.86,38,,8.208,percent of total billed charges,38% of total billed charges,118.8,40,,4.504,percent of total billed charges,40% of total billed charges,1964.94,3616,
VKORC1 GENE,4030046,CDM,310,RC,81355,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,250,50,,32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,24,percent of total billed charges,50% of total billed charges,159.75,31.95,,2.424,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,2.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,37.392,percent of total billed charges,38% of total billed charges,200,40,,3.032,percent of total billed charges,40% of total billed charges,1965.94,3617,
3A4,4030047,CDM,310,RC,81401,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,385.84,136.6,,24,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,385.84,136.6,,39.2,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,0.488,percent of total billed charges,38% of total billed charges,200,40,,2.6,percent of total billed charges,40% of total billed charges,1966.94,3618,
3A5,4030048,CDM,310,RC,81401,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,385.84,136.6,,39.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,385.84,136.6,,55.6,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,2.72,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,2.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,67.736,percent of total billed charges,38% of total billed charges,200,40,,3.408,percent of total billed charges,40% of total billed charges,1967.94,3619,
ApoE,4030049,CDM,310,RC,81401,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,385.84,136.6,,55.6,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,385.84,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,9.28,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,9.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,43.84,percent of total billed charges,38% of total billed charges,200,40,,11.616,percent of total billed charges,40% of total billed charges,1968.94,3620,
SLCO1B1,4030050,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,14.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,110.4,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,4.864,percent of total billed charges,38% of total billed charges,200,40,,4.312,percent of total billed charges,40% of total billed charges,1969.94,3621,
OPRM1,4030051,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,110.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,28.8,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,3.648,percent of total billed charges,38% of total billed charges,200,40,,30.72,percent of total billed charges,40% of total billed charges,1970.94,3622,
HTR2A,4030052,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,28.8,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,6.384,percent of total billed charges,38% of total billed charges,200,40,,5.032,percent of total billed charges,40% of total billed charges,1971.94,3623,
HTR2C,4030053,CDM,310,RC,81479,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,216.61,136.6,,20,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.61,136.6,,3.784,fee schedule,136.60% of BCBS custom fee schedule,159.75,31.95,,5.544,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,5.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,7.904,percent of total billed charges,38% of total billed charges,200,40,,6.944,percent of total billed charges,40% of total billed charges,1972.94,3624,
"NEW PATIENT, VISIT LEVEL 2.",4050002,CDM,510,RC,99202,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,177.36,136.6,,3.784,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,198,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,6.408,fee schedule,110% of LA custom fee schedule,32.87,100,,6.408,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,68.4,38,,1.52,percent of total billed charges,38% of total billed charges,32.87,100,,8.016,Fee Schedule,100% of LA custom fee schedule,1973.94,3625,
NEW PATIENT VISIT LEVEL 3,4050003,CDM,510,RC,99203,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,204.05,136.6,,198,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,3.784,fee schedule,136.60% of BCBS custom fee schedule,30,110,,204.48,fee schedule,110% of LA custom fee schedule,37.83,100,,204.48,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,11.4,38,,44.688,percent of total billed charges,38% of total billed charges,37.83,100,,256,Fee Schedule,100% of LA custom fee schedule,1974.94,3626,
"NEW PATIENT, VISIT LEVEL 4.",4050004,CDM,510,RC,99204,HCPCS,OUTPATIENT,,,45,27,,,,,,other,Not separately reimbursable,296.91,136.6,,3.784,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,198,fee schedule,136.60% of BCBS custom fee schedule,45,110,,1.568,fee schedule,110% of LA custom fee schedule,56.77,100,,1.568,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,17.1,38,,1.52,percent of total billed charges,38% of total billed charges,56.77,100,,1.968,Fee Schedule,100% of LA custom fee schedule,1975.94,3627,
"NEW PATIENT, VISIT LEVEL 5.",4050005,CDM,510,RC,99205,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,296.91,136.6,,198,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,62.45,110,,5.112,fee schedule,110% of LA custom fee schedule,56.77,100,,5.112,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,26.6,38,,12.768,percent of total billed charges,38% of total billed charges,56.77,100,,6.4,Fee Schedule,100% of LA custom fee schedule,1976.94,3628,
"ESTABLISHED PATIENT, VISIT LEVEL 1",4050011,CDM,510,RC,99211,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,177.36,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,5.112,fee schedule,110% of LA custom fee schedule,32.87,100,,5.112,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,38,38,,0.896,percent of total billed charges,38% of total billed charges,32.87,100,,6.4,Fee Schedule,100% of LA custom fee schedule,1977.94,3629,
"ESTABLISHED PATIENT, VISIT LEVEL 2.",4050012,CDM,510,RC,99212,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,177.36,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,78,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,6.392,fee schedule,110% of LA custom fee schedule,32.87,100,,6.392,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,53.2,38,,3.952,percent of total billed charges,38% of total billed charges,32.87,100,,8,Fee Schedule,100% of LA custom fee schedule,1978.94,3630,
ESTABLISHED VISIT LEVEL 3,4050013,CDM,510,RC,99213,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,204.05,136.6,,78,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,30,110,,8.176,fee schedule,110% of LA custom fee schedule,37.83,100,,8.176,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,11.4,38,,67.792,percent of total billed charges,38% of total billed charges,37.83,100,,10.24,Fee Schedule,100% of LA custom fee schedule,1979.94,3631,
"ESTABLISHED PATIENT, VISIT LEVEL 4.",4050014,CDM,510,RC,99214,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,296.91,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,98,fee schedule,136.60% of BCBS custom fee schedule,50,110,,15.08,fee schedule,110% of LA custom fee schedule,56.77,100,,15.08,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,19,38,,48.336,percent of total billed charges,38% of total billed charges,56.77,100,,18.88,Fee Schedule,100% of LA custom fee schedule,1980.94,3632,
"ESTABLISHED PATIENT, VISIT LEVEL 5.",4050015,CDM,361,RC,99215,HCPCS,OUTPATIENT,,,108,64.8,,,,,,other,Not separately reimbursable,296.91,136.6,,98,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,37.96,35.15,,152.592,percent of total billed charges,35.15% of total billed charges,101.6,31.95,,152.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,0.304,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,34.51,31.95,,191.04,percent of total billed charges,31.95% of total billed charges,1981.94,3633,
SKIN SUB GRAFT T/ARM/LG CHILD 1ST,4050030,CDM,361,RC,15273,HCPCS,OUTPATIENT,,,4665,2799,,,,,,other,Not separately reimbursable,1451.21,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1451.21,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,1639.75,35.15,,20.448,fee schedule,35.15% of LA custom fee schedule,1490.47,31.95,,20.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,3050,100,,0.912,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1490.47,31.95,,25.6,Fee Schedule,31.95% of LA custom fee schedule,1982.94,3634,
SKIN SUB GRAFT T/A/L CHILD ADDL,4050031,CDM,361,RC,15274,HCPCS,OUTPATIENT,,,1070,642,,,,,,other,Not separately reimbursable,952.94,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,952.94,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,376.11,35.15,,4.264,fee schedule,35.15% of LA custom fee schedule,341.87,31.95,,4.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,16.112,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,341.87,31.95,,5.344,Fee Schedule,31.95% of LA custom fee schedule,1983.94,3635,
SKIN SUB GRAFT FACE/NK/HF/G 1ST,4050032,CDM,361,RC,15275,HCPCS,OUTPATIENT,,,3025,1815,,,,,,other,Not separately reimbursable,952.94,136.6,,22,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,952.94,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,1063.29,35.15,,4.28,fee schedule,35.15% of LA custom fee schedule,966.49,31.95,,4.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1300,100,,7.872,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,966.49,31.95,,5.36,Fee Schedule,31.95% of LA custom fee schedule,1984.94,3636,
SKIN SUB GRAFT FACE/NK/HF/G ADDL,4050033,CDM,361,RC,15276,HCPCS,OUTPATIENT,,,390,234,,,,,,other,Not separately reimbursable,351.13,136.6,,19.2,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,351.13,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,137.09,35.15,,3.576,fee schedule,35.15% of LA custom fee schedule,124.61,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,6.688,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,124.61,31.95,,4.48,Fee Schedule,31.95% of LA custom fee schedule,1985.94,3637,
WOUND PREP TRK/ARM/LEG ADDL,4050034,CDM,361,RC,15003,HCPCS,OUTPATIENT,,,1450,870,,,,,,other,Not separately reimbursable,1328.08,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1328.08,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,509.68,35.15,,3.576,fee schedule,35.15% of LA custom fee schedule,463.28,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,0.912,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,463.28,31.95,,4.48,Fee Schedule,31.95% of LA custom fee schedule,1986.94,3638,
WOUND PREP F/N/HF/G ADDL,4050035,CDM,361,RC,15005,HCPCS,OUTPATIENT,,,1450,870,,,,,,other,Not separately reimbursable,1328.08,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1328.08,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,509.68,35.15,,0.768,fee schedule,35.15% of LA custom fee schedule,463.28,31.95,,0.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,43.776,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,463.28,31.95,,0.96,Fee Schedule,31.95% of LA custom fee schedule,1987.94,3639,
OP PROC <15 MIN,4050040,CDM,361,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,34,percent of total billed charges,50% of total billed charges,9.59,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,6.384,percent of total billed charges,38% of total billed charges,12,40,,14.4,percent of total billed charges,40% of total billed charges,1988.94,3640,
OP PROC 15-30 MIN,4050042,CDM,361,RC,,,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,77.6,percent of total billed charges,50% of total billed charges,15.98,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,0.608,percent of total billed charges,38% of total billed charges,20,40,,0.32,percent of total billed charges,40% of total billed charges,1989.94,3641,
OP PROC >30 MIN,4050044,CDM,361,RC,,,OUTPATIENT,,,108,64.8,,91.8,85,,73.44,Percent of total billed charges,85% of total billed charges,54,50,,77.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,54,50,,44,percent of total billed charges,50% of total billed charges,34.51,31.95,,170.96,percent of total billed charges,31.95% of total billed charges,34.51,31.95,,170.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.04,38,,28.88,percent of total billed charges,38% of total billed charges,43.2,40,,214.032,percent of total billed charges,40% of total billed charges,1990.94,3642,
SLCTV WND DEBRMENT 20CM/<  97597,4050050,CDM,761,RC,97597,HCPCS,OUTPATIENT,,,306,183.6,,,,,,other,Not separately reimbursable,170.87,136.6,,44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,170.87,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,107.56,35.15,,205.152,percent of total billed charges,35.15% of total billed charges,101.6,31.95,,205.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,12.16,other,Not separately reimbursable,97.77,31.95,,256.84,percent of total billed charges,31.95% of total billed charges,1991.94,3643,
SLCTV WND DEBRIDEM ADDL 20CM 97598.,4050051,CDM,761,RC,97598,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,213.7,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,213.7,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,26.36,35.15,,1.008,percent of total billed charges,35.15% of total billed charges,101.6,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,1.216,other,Not separately reimbursable,23.96,31.95,,1.264,percent of total billed charges,31.95% of total billed charges,1992.94,3644,
DEBRIDE SUBQ TISSUE - 1st 20 CM?,4050052,CDM,761,RC,11042,HCPCS,OUTPATIENT,,,585,351,,,,,,other,Not separately reimbursable,1307.44,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1307.44,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,186.91,31.95,,660.616,percent of total billed charges,31.95% of total billed charges,186.91,31.95,,660.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,20.184,other,Not separately reimbursable,234,40,,827.064,percent of total billed charges,40% of total billed charges,1993.94,3645,
DEBRIDE SUBQ TISSUE - EACH ADDL 20 CM?,4050053,CDM,761,RC,11045,HCPCS,OUTPATIENT,,,54,32.4,,,,,,other,Not separately reimbursable,0.01,136.6,,72,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,18.98,35.15,,2.808,fee schedule,35.15% of LA custom fee schedule,17.25,31.95,,2.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,3.832,other,Not separately reimbursable,17.25,31.95,,3.52,Fee Schedule,31.95% of LA custom fee schedule,1994.94,3646,
DEBRIDE MUSCLE/FASCIA - FIRST 20 CM?.,4050054,CDM,761,RC,11043,HCPCS,OUTPATIENT,,,906,543.6,,,,,,other,Not separately reimbursable,2053.7,136.6,,8.4,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2053.7,136.6,,2.4,fee schedule,136.60% of BCBS custom fee schedule,289.47,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,289.47,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,436.544,other,Not separately reimbursable,362.4,40,,14.72,percent of total billed charges,40% of total billed charges,1995.94,3647,
DEBRIDE MUSCLE/FASCIA - EACH ADDL 20 CM?.,4050055,CDM,761,RC,11046,HCPCS,OUTPATIENT,,,114,68.4,,,,,,other,Not separately reimbursable,57,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57,50,,80,percent of total billed charges,50% of total billed charges,40.07,35.15,,16.48,fee schedule,35.15% of LA custom fee schedule,36.42,31.95,,10.776,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,1.824,other,Not separately reimbursable,36.42,31.95,,14.976,Fee Schedule,31.95% of LA custom fee schedule,1996.94,3648,
DEBRIDE BONE - FIRST 20CM?.,4050056,CDM,761,RC,11044,HCPCS,OUTPATIENT,,,2472,1483.2,,,,,,other,Not separately reimbursable,3962.6,136.6,,80,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3962.6,136.6,,30,fee schedule,136.60% of BCBS custom fee schedule,789.8,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,789.8,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,1.52,other,Not separately reimbursable,988.8,40,,14.4,percent of total billed charges,40% of total billed charges,1997.94,3649,
DEBRIDE BONE - EACH ADDL 20 CM?.,4050057,CDM,761,RC,11047,HCPCS,OUTPATIENT,,,205,123,,,,,,other,Not separately reimbursable,102.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,102.5,50,,160,percent of total billed charges,50% of total billed charges,72.06,35.15,,30.928,fee schedule,35.15% of LA custom fee schedule,65.5,31.95,,30.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,3.952,other,Not separately reimbursable,65.5,31.95,,38.72,Fee Schedule,31.95% of LA custom fee schedule,1998.94,3650,
WOUND(S) CARE NON-SELECTIVE.,4050058,CDM,761,RC,97602,HCPCS,OUTPATIENT,,,306,183.6,,,,,,other,Not separately reimbursable,399.06,136.6,,160,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,399.06,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,107.56,35.15,,164.504,percent of total billed charges,35.15% of total billed charges,101.92,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,41.648,other,Not separately reimbursable,97.77,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,1999.94,3651,
APPLICATION OF UNNA BOOT LT.,4050059,CDM,361,RC,29580,HCPCS,OUTPATIENT,,,250,150,LT,,,,,other,Not separately reimbursable,501.61,136.6,,70,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,111.608,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,10.776,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,3.208,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,79.88,31.95,,101.448,Fee Schedule,31.95% of LA custom fee schedule,2000.94,3652,
APPLICATION OF UNNA BOOT RT.,4050060,CDM,361,RC,29580,HCPCS,OUTPATIENT,,,250,150,RT,,,,,other,Not separately reimbursable,501.61,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,98.152,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,98.152,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,1.216,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,79.88,31.95,,122.88,Fee Schedule,31.95% of LA custom fee schedule,2001.94,3653,
APPLY MULTLAY COMPRS LWR LEG LT,4050061,CDM,361,RC,29581,HCPCS,OUTPATIENT,,,250,150,LT,,,,,other,Not separately reimbursable,298.8,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,298.8,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,17.712,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,10.776,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,0.608,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,79.88,31.95,,16.104,Fee Schedule,31.95% of LA custom fee schedule,2002.94,3654,
APPLY MULTLAY COMPRS LWR LEG RT,4050062,CDM,361,RC,29581,HCPCS,OUTPATIENT,,,250,150,RT,,,,,other,Not separately reimbursable,298.8,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,298.8,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,1.408,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,10.776,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,34.048,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,79.88,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2003.94,3655,
ID ABSCESS (SIMPLE).,4050063,CDM,761,RC,10060,HCPCS,OUTPATIENT,,,306,183.6,,,,,,other,Not separately reimbursable,495.68,136.6,,34,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,44,fee schedule,136.60% of BCBS custom fee schedule,97.77,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,97.77,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,12.768,other,Not separately reimbursable,122.4,40,,1.28,percent of total billed charges,40% of total billed charges,2004.94,3656,
ID OF HEMATOMA/FLUID.,4050065,CDM,761,RC,10140,HCPCS,OUTPATIENT,,,2472,1483.2,,,,,,other,Not separately reimbursable,3962.6,136.6,,44,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3962.6,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,789.8,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,789.8,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,27.056,other,Not separately reimbursable,988.8,40,,1.28,percent of total billed charges,40% of total billed charges,2005.94,3657,
CHEMICAL CAUTERY TISSUE,4050066,CDM,761,RC,17250,HCPCS,OUTPATIENT,,,306,183.6,,,,,,other,Not separately reimbursable,265.43,136.6,,68,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,107.56,35.15,,36.272,fee schedule,35.15% of LA custom fee schedule,97.77,31.95,,10.776,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,3.04,other,Not separately reimbursable,97.77,31.95,,32.976,Fee Schedule,31.95% of LA custom fee schedule,2006.94,3658,
APLIGRAF PER UNIT,4050067,CDM,636,RC,Q4101,HCPCS,OUTPATIENT,,,64,38.4,,,,,,other,Not separately reimbursable,45.53,136.6,,92,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.53,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,22.5,35.15,,48.648,fee schedule,35.15% of LA custom fee schedule,20.45,31.95,,10.776,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,13.68,other,Not separately reimbursable,20.45,31.95,,44.216,Fee Schedule,31.95% of LA custom fee schedule,2007.94,3659,
DERMAGRAFT PER UNIT,4050068,CDM,636,RC,Q4106,HCPCS,OUTPATIENT,,,71,42.6,,,,,,other,Not separately reimbursable,41.8,136.6,,56,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,41.8,136.6,,100,fee schedule,136.60% of BCBS custom fee schedule,24.96,35.15,,39.088,fee schedule,35.15% of LA custom fee schedule,22.68,31.95,,109.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,10.336,other,Not separately reimbursable,22.68,31.95,,35.528,Fee Schedule,31.95% of LA custom fee schedule,2008.94,3660,
OASIS WOUND MATRIX PER UNIT,4050069,CDM,636,RC,Q4102,HCPCS,OUTPATIENT,,,18,10.8,,,,,,other,Not separately reimbursable,18.78,136.6,,100,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,18.78,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,6.33,35.15,,39.648,percent of total billed charges,35.15% of total billed charges,102.24,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,9.384,other,Not separately reimbursable,5.75,31.95,,36.04,percent of total billed charges,31.95% of total billed charges,2009.94,3661,
WOUND PREP TRK/ARM/LEG 1ST,4050070,CDM,361,RC,15002,HCPCS,OUTPATIENT,,,2854,1712.4,,,,,,other,Not separately reimbursable,1328.08,136.6,,200,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1328.08,136.6,,480,fee schedule,136.60% of BCBS custom fee schedule,1003.18,35.15,,63.264,fee schedule,35.15% of LA custom fee schedule,911.85,31.95,,63.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1300,100,,1.824,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,911.85,31.95,,79.2,Fee Schedule,31.95% of LA custom fee schedule,2010.94,3662,
WOUND PREP F/N/HF/G 1ST,4050071,CDM,361,RC,15004,HCPCS,OUTPATIENT,,,906,543.6,,,,,,other,Not separately reimbursable,1328.08,136.6,,480,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1328.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,318.46,35.15,,3.448,fee schedule,35.15% of LA custom fee schedule,289.47,31.95,,3.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,1.52,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,289.47,31.95,,4.32,Fee Schedule,31.95% of LA custom fee schedule,2011.94,3663,
SKIN SUB GRAFT TRNK/ARM/LEG - FIRST 100 CM?,4050072,CDM,361,RC,15271,HCPCS,OUTPATIENT,,,2854,1712.4,,,,,,other,Not separately reimbursable,952.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,952.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1003.18,35.15,,320.52,fee schedule,35.15% of LA custom fee schedule,911.85,31.95,,320.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1300,100,,0.304,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,911.85,31.95,,401.28,Fee Schedule,31.95% of LA custom fee schedule,2012.94,3664,
SKIN SUB GRAFT T/A/L - EACH ADDL 100 CM?,4050073,CDM,361,RC,15272,HCPCS,OUTPATIENT,,,295,177,,,,,,other,Not separately reimbursable,351.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,351.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,103.69,35.15,,5.216,fee schedule,35.15% of LA custom fee schedule,94.25,31.95,,109.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,8.816,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,94.25,31.95,,4.744,Fee Schedule,31.95% of LA custom fee schedule,2013.94,3665,
SKIN SUB GRAFT F/N/HF/G CHILD 1ST,4050074,CDM,361,RC,15277,HCPCS,OUTPATIENT,,,2854,1712.4,,,,,,other,Not separately reimbursable,1451.21,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1451.21,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1003.18,35.15,,8.352,fee schedule,35.15% of LA custom fee schedule,911.85,31.95,,109.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,1300,100,,9.728,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,911.85,31.95,,7.592,Fee Schedule,31.95% of LA custom fee schedule,2014.94,3666,
SKIN SUB GRAFT F/N/HF/G CHILD ADDL,4050075,CDM,361,RC,15278,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,952.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,952.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,210.9,35.15,,14.312,fee schedule,35.15% of LA custom fee schedule,191.7,31.95,,14.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,13.376,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,191.7,31.95,,17.92,Fee Schedule,31.95% of LA custom fee schedule,2015.94,3667,
VASCULAR ULTRASOUND,4050076,CDM,929,RC,93970,HCPCS,OUTPATIENT,,,452,271.2,,,,,,other,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.88,35.15,,3.376,fee schedule,35.15% of LA custom fee schedule,144.41,31.95,,109.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,171.76,38,,1.216,percent of total billed charges,38% of total billed charges,144.41,31.95,,3.064,Fee Schedule,31.95% of LA custom fee schedule,2016.94,3668,
NEG PRESS WOUND TX </=50 CM,4050077,CDM,761,RC,97605,HCPCS,OUTPATIENT,,,306,183.6,,,,,,other,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,107.56,35.15,,6.392,percent of total billed charges,35.15% of total billed charges,102.24,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,4.344,other,Not separately reimbursable,97.77,31.95,,8,percent of total billed charges,31.95% of total billed charges,2017.94,3669,
11055 TRIM SKIN LESION TECH FEE,4050078,CDM,361,RC,11055,HCPCS,OUTPATIENT,,,340,204,,,,,,other,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,119.51,35.15,,3.936,fee schedule,35.15% of LA custom fee schedule,108.63,31.95,,109.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,3.648,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,108.63,31.95,,3.576,Fee Schedule,31.95% of LA custom fee schedule,2018.94,3670,
11056 TRIM SKIN LESIONS 2 TO 4 TECH FEE,4050079,CDM,361,RC,11056,HCPCS,OUTPATIENT,,,360,216,,,,,,other,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,115.02,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,3.648,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,115.02,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2019.94,3671,
11057 TRIM SKIN LESIONS OVER 4 TECH FEE,4050080,CDM,361,RC,11057,HCPCS,OUTPATIENT,,,380,228,,,,,,other,Not separately reimbursable,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,9,fee schedule,35.15% of LA custom fee schedule,121.41,31.95,,109.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,3.648,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,121.41,31.95,,8.176,Fee Schedule,31.95% of LA custom fee schedule,2020.94,3672,
11719 TRIM NAIL(S) ANY NUMBER TECH FEE,4050081,CDM,361,RC,11719,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.05,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,53.68,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,4.56,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,53.68,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2021.94,3673,
11720 DEBRIDE NAIL 1-5 TECH FEE,4050082,CDM,361,RC,11720,HCPCS,OUTPATIENT,,,188,112.8,,,,,,other,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,66.08,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,60.07,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,4.544,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,60.07,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2022.94,3674,
11721 DEBRIDE NAIL 6 OR MORE TECH FEE,4050083,CDM,361,RC,11721,HCPCS,OUTPATIENT,,,204,122.4,,,,,,other,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,71.71,35.15,,115.024,fee schedule,35.15% of LA custom fee schedule,65.18,31.95,,115.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,4.104,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,65.18,31.95,,144,Fee Schedule,31.95% of LA custom fee schedule,2023.94,3675,
G0127 TRIM DYSTROPHIC NAILS ANY NUMBER TECH FEE,4050084,CDM,360,RC,G0127,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,84,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84,50,,67.2,percent of total billed charges,50% of total billed charges,53.68,31.95,,6.352,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,4.104,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,67.2,40,,5.776,percent of total billed charges,40% of total billed charges,2024.94,3676,
ABI UPR/L XTREMITY ART 2 LEVELS REPORT,4050085,CDM,929,RC,93922,HCPCS,OUTPATIENT,,,320,192,TC,,,,,other,Not separately reimbursable,322.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,322.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.48,35.15,,14.624,fee schedule,35.15% of LA custom fee schedule,102.24,31.95,,109.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,121.6,38,,4.104,percent of total billed charges,38% of total billed charges,102.24,31.95,,13.288,Fee Schedule,31.95% of LA custom fee schedule,2025.94,3677,
ABI UPR/LXTR ART STDY 3+ LVLS,4050086,CDM,929,RC,93923,HCPCS,OUTPATIENT,,,408,244.8,TC,,,,,other,Not separately reimbursable,322.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,322.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,143.41,35.15,,11.808,fee schedule,35.15% of LA custom fee schedule,130.36,31.95,,111.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155.04,38,,4.104,percent of total billed charges,38% of total billed charges,130.36,31.95,,10.736,Fee Schedule,31.95% of LA custom fee schedule,2026.94,3678,
11730 REMOVAL OF NAIL BED TECH FEE,4050087,CDM,361,RC,11730,HCPCS,OUTPATIENT,,,530,318,,,,,,other,Not separately reimbursable,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,186.3,35.15,,11.808,fee schedule,35.15% of LA custom fee schedule,169.34,31.95,,112.464,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,4.104,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,169.34,31.95,,10.736,Fee Schedule,31.95% of LA custom fee schedule,2027.94,3679,
"TANGENTIAL BIOPSY SKIN, SINGLE LESION",4050088,CDM,761,RC,11102,HCPCS,OUTPATIENT,,,530,318,,,,,,other,Not separately reimbursable,742.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,742.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,186.3,35.15,,12.376,fee schedule,35.15% of LA custom fee schedule,169.34,31.95,,113.232,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,2.736,other,Not separately reimbursable,169.34,31.95,,11.248,Fee Schedule,31.95% of LA custom fee schedule,2028.94,3680,
Tangntl bx skin ea sep/addl,4050089,CDM,761,RC,11103,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,223.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,223.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,4.216,fee schedule,35.15% of LA custom fee schedule,63.9,31.95,,113.232,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,2.736,other,Not separately reimbursable,63.9,31.95,,3.832,Fee Schedule,31.95% of LA custom fee schedule,2029.94,3681,
APPLICATION RIGID TOTAL CONTACT LEG CAST,4050090,CDM,361,RC,29445,HCPCS,OUTPATIENT,,,570,342,,,,,,other,Not separately reimbursable,874.49,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,874.49,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,200.36,35.15,,2.528,fee schedule,35.15% of LA custom fee schedule,182.12,31.95,,113.232,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,2.736,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,182.12,31.95,,2.304,Fee Schedule,31.95% of LA custom fee schedule,2030.94,3682,
WEDGE EXCISION SKIN NAIL FOLD,4050091,CDM,361,RC,11765,HCPCS,OUTPATIENT,,,950,570,,,,,,other,Not separately reimbursable,409.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,409.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,333.93,35.15,,4.216,fee schedule,35.15% of LA custom fee schedule,303.53,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,3.04,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,303.53,31.95,,3.832,Fee Schedule,31.95% of LA custom fee schedule,2031.94,3683,
TX SUPERFICIAL WOUND DEHISCENCE SMPL CLOSURE,4050092,CDM,361,RC,12020,HCPCS,OUTPATIENT,,,1638,982.8,,,,,,other,Not separately reimbursable,819,50,,655.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,819,50,,655.2,percent of total billed charges,50% of total billed charges,523.34,31.95,,15.184,percent of total billed charges,31.95% of total billed charges,523.34,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,4.104,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,655.2,40,,13.8,percent of total billed charges,40% of total billed charges,2032.94,3684,
SURGIGRAFT PER SQ CM,4050093,CDM,636,RC,Q4183,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,122.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,122.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,927.96,percent of total billed charges,35.15% of total billed charges,102.24,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,2.736,other,Not separately reimbursable,111.83,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,2033.94,3685,
NEG PRESS WND TX NON DME </=50 SQ CM,4050094,CDM,761,RC,97607,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,390.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,390.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,210.9,35.15,,39.736,percent of total billed charges,35.15% of total billed charges,102.24,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,61.408,other,Not separately reimbursable,191.7,31.95,,36.12,percent of total billed charges,31.95% of total billed charges,2034.94,3686,
PUNC ASP ABSCESS/HEM/BULL/CYST,4050095,CDM,761,RC,10160,HCPCS,OUTPATIENT,,,639,383.4,,,,,,other,Not separately reimbursable,319.5,50,,255.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,319.5,50,,255.6,percent of total billed charges,50% of total billed charges,204.16,31.95,,21.912,percent of total billed charges,31.95% of total billed charges,204.16,31.95,,116.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,3.952,other,Not separately reimbursable,255.6,40,,19.92,percent of total billed charges,40% of total billed charges,2035.94,3687,
"NEW PATIENT, VISIT LEVEL 2 FMC",4050102,CDM,984,RC,99202,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4639.8,other,Not separately reimbursable,,31.95,,116.296,other,Not separately reimbursable,45.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,4217.4,other,Not separately reimbursable,2036.94,3688,
NEW PATIENT VISIT LEVEL 3 Prof,4050103,CDM,984,RC,99203,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4639.8,other,Not separately reimbursable,,31.95,,116.296,other,Not separately reimbursable,70,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,4217.4,other,Not separately reimbursable,2037.94,3689,
"NEW PATIENT, VISIT LEVEL 4 FMC",4050104,CDM,984,RC,99204,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4639.8,other,Not separately reimbursable,,31.95,,11.76,other,Not separately reimbursable,127.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,4217.4,other,Not separately reimbursable,2038.94,3690,
"NEW PATIENT, VISIT LEVEL 5 FMC",4050105,CDM,984,RC,99205,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,208.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4639.8,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,4217.4,other,Not separately reimbursable,2039.94,3691,
"ESTABLISHED PATIENT, VISIT LEVEL 1 FMC",4050106,CDM,984,RC,99211,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4639.8,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,8.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,4217.4,other,Not separately reimbursable,2040.94,3692,
"ESTABLISHED PATIENT, VISIT LEVEL 2 FMC",4050107,CDM,984,RC,99212,HCPCS,OUTPATIENT,,,35,21,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,658.008,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,33.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.728,other,Not separately reimbursable,,,,598.104,other,Not separately reimbursable,2041.94,3693,
ESTABLISHED VISIT LEVEL 3,4050108,CDM,984,RC,99213,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,787.36,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,50,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.816,other,Not separately reimbursable,,,,715.68,other,Not separately reimbursable,2042.94,3694,
"ESTABLISHED PATIENT, VISIT LEVEL 4 FMC",4050109,CDM,984,RC,99214,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,600.168,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,80,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.816,other,Not separately reimbursable,,,,545.528,other,Not separately reimbursable,2043.94,3695,
"ESTABLISHED PATIENT, VISIT LEVEL 5 FMC",4050110,CDM,984,RC,99215,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,591.36,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,32.224,other,Not separately reimbursable,,,,537.528,other,Not separately reimbursable,2044.94,3696,
SLCTV WND DEBRMENT 20CM/<  97597 FMC,4050200,CDM,984,RC,97597,HCPCS,OUTPATIENT,,,47,28.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,68.032,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,33.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,61.84,other,Not separately reimbursable,2045.94,3697,
SLCTV WND DEBRIDEM ADDL 20CM 97598 FMC,4050201,CDM,984,RC,97598,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,22.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,46.008,other,Not separately reimbursable,,31.95,,46.008,other,Not separately reimbursable,23.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,57.6,other,Not separately reimbursable,2046.94,3698,
DEBRIDE SUBQ TISSUE - 1st 20 CM? PROF,4050202,CDM,984,RC,11042,HCPCS,OUTPATIENT,,,127,76.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,214.704,other,Not separately reimbursable,,31.95,,214.704,other,Not separately reimbursable,57.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,268.8,other,Not separately reimbursable,2047.94,3699,
DEBRIDE SUBQ TISSUE - EACH ADD 20 CM? FMC,4050203,CDM,984,RC,11045,HCPCS,OUTPATIENT,,,54,32.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.36,other,Not separately reimbursable,,31.95,,8.36,other,Not separately reimbursable,24.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,10.472,other,Not separately reimbursable,2048.94,3700,
DEBRIDE MUSCLE/FASCIA - FIRST 20 CM? FMC,4050204,CDM,984,RC,11043,HCPCS,OUTPATIENT,,,322,193.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,252.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,0.512,other,Not separately reimbursable,,31.95,,0.512,other,Not separately reimbursable,145.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.304,other,Not separately reimbursable,,,,0.64,other,Not separately reimbursable,2049.94,3701,
DEBRIDE MUSCLE/FASCIA - EACH ADDL 20 CM? FMC,4050205,CDM,984,RC,11046,HCPCS,OUTPATIENT,,,116,69.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,81.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,319.824,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,52.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.912,other,Not separately reimbursable,,,,290.704,other,Not separately reimbursable,2050.94,3702,
DEBRIDE BONE - FIRST 20CM? FMC,4050206,CDM,984,RC,11044,HCPCS,OUTPATIENT,,,477,286.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,346.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.896,other,Not separately reimbursable,,31.95,,8.896,other,Not separately reimbursable,214.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,11.136,other,Not separately reimbursable,2051.94,3703,
DEBRIDE BONE - EACH ADDL 20 CM? FMC,4050207,CDM,984,RC,11047,HCPCS,OUTPATIENT,,,207,124.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.896,other,Not separately reimbursable,,31.95,,8.896,other,Not separately reimbursable,92.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,11.136,other,Not separately reimbursable,2052.94,3704,
WOUND(S) CARE NON-SELECTIVE FMC,4050208,CDM,984,RC,97602,HCPCS,OUTPATIENT,,,66,39.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,32.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.176,other,Not separately reimbursable,,31.95,,1.176,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,16.416,other,Not separately reimbursable,,,,1.472,other,Not separately reimbursable,2053.94,3705,
APPLICATION OF UNNA BOOT LT FMC,4050209,CDM,984,RC,29580,HCPCS,OUTPATIENT,,,73,43.8,LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.464,other,Not separately reimbursable,,31.95,,8.464,other,Not separately reimbursable,25.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.024,other,Not separately reimbursable,,,,10.592,other,Not separately reimbursable,2054.94,3706,
APPLICATION OF UNNA BOOT RT FMC,4050210,CDM,984,RC,29580,HCPCS,OUTPATIENT,,,73,43.8,RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.84,other,Not separately reimbursable,,31.95,,1.84,other,Not separately reimbursable,25.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.024,other,Not separately reimbursable,,,,2.304,other,Not separately reimbursable,2055.94,3707,
PROF APPLY MULTLAY COMPRS LWR LEG LT,4050211,CDM,984,RC,29581,HCPCS,OUTPATIENT,,,27,16.2,LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,126.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,62.728,other,Not separately reimbursable,,31.95,,62.728,other,Not separately reimbursable,25.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.024,other,Not separately reimbursable,,,,78.528,other,Not separately reimbursable,2056.94,3708,
APPLY MULTLAY COMPRS LWR LEG RT PROF,4050212,CDM,984,RC,29581,HCPCS,OUTPATIENT,,,27,16.2,RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,126.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,0.464,other,Not separately reimbursable,,31.95,,0.464,other,Not separately reimbursable,25.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.024,other,Not separately reimbursable,,,,0.576,other,Not separately reimbursable,2057.94,3709,
ID ABSCESS (SIMPLE) FMC,4050213,CDM,984,RC,10060,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.4,other,Not separately reimbursable,,31.95,,2.4,other,Not separately reimbursable,99.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.024,other,Not separately reimbursable,,,,3.008,other,Not separately reimbursable,2058.94,3710,
ID OF HEMATOMA/FLUID FMC,4050215,CDM,984,RC,10140,HCPCS,OUTPATIENT,,,243,145.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.832,other,Not separately reimbursable,,31.95,,11.832,other,Not separately reimbursable,111.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.272,other,Not separately reimbursable,,,,14.816,other,Not separately reimbursable,2059.94,3711,
CHEMICAL CAUTERY TISSUE FMC,4050216,CDM,984,RC,17250,HCPCS,OUTPATIENT,,,76,45.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,85.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,86.904,other,Not separately reimbursable,,31.95,,86.904,other,Not separately reimbursable,35.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.128,other,Not separately reimbursable,,,,108.8,other,Not separately reimbursable,2060.94,3712,
ABI UPR/L XTREMITY ART 2 LEVELS REPORT FMC,4050217,CDM,984,RC,93922,HCPCS,OUTPATIENT,,,40,24,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,108.608,other,Not separately reimbursable,,31.95,,108.608,other,Not separately reimbursable,40,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.128,other,Not separately reimbursable,,,,135.968,other,Not separately reimbursable,2061.94,3713,
ABI UPR/LXTR ART STDY 3+ LVLS,4050218,CDM,984,RC,93923,HCPCS,OUTPATIENT,,,68,40.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,166.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.968,other,Not separately reimbursable,,31.95,,1.968,other,Not separately reimbursable,68,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.128,other,Not separately reimbursable,,,,2.464,other,Not separately reimbursable,2062.94,3714,
NEG PRESS WOUND TX </= 50 CM,4050219,CDM,984,RC,97605,HCPCS,OUTPATIENT,,,66,39.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,23.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.208,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2063.94,3715,
11055 TRIM SKIN LESION PRO FEE,4050220,CDM,984,RC,11055,HCPCS,OUTPATIENT,,,136,81.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,58.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.224,other,Not separately reimbursable,,31.95,,2.224,other,Not separately reimbursable,14.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.824,other,Not separately reimbursable,,,,2.784,other,Not separately reimbursable,2064.94,3716,
11056 TRIM SKIN LESIONS 2 TO 4 PRO FEE,4050221,CDM,984,RC,11056,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,21.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2065.94,3717,
11057 TRIM SKIN LESIONS OVER 4 PRO FEE,4050222,CDM,984,RC,11057,HCPCS,OUTPATIENT,,,191,114.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,79.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,122.64,other,Not separately reimbursable,,31.95,,122.64,other,Not separately reimbursable,27.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,153.536,other,Not separately reimbursable,2066.94,3718,
11719 TRIM NAIL(S) ANY NUMBER PRO FEE,4050223,CDM,984,RC,11719,HCPCS,OUTPATIENT,,,42,25.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,15.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,122.64,other,Not separately reimbursable,,31.95,,122.64,other,Not separately reimbursable,7.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,153.536,other,Not separately reimbursable,2067.94,3719,
11720 DEBRIDE NAIL 1-5 PRO FEE,4050224,CDM,984,RC,11720,HCPCS,OUTPATIENT,,,95,57,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,137.104,other,Not separately reimbursable,,31.95,,137.104,other,Not separately reimbursable,13.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,171.648,other,Not separately reimbursable,2068.94,3720,
11721 DEBRIDE NAIL 6 OR MORE PRO FEE,4050225,CDM,984,RC,11721,HCPCS,OUTPATIENT,,,132,79.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,31.464,other,Not separately reimbursable,,31.95,,31.464,other,Not separately reimbursable,22.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,39.392,other,Not separately reimbursable,2069.94,3721,
G0127 TRIM DYSTROPHIC NAILS ANY NUMBER PRO FEE,4050226,CDM,984,RC,G0127,HCPCS,OUTPATIENT,,,69,41.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.632,other,Not separately reimbursable,,31.95,,3.632,other,Not separately reimbursable,7.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,29.184,other,Not separately reimbursable,,,,4.544,other,Not separately reimbursable,2070.94,3722,
11730 REMOVAL OF NAIL BED PRO FEE,4050227,CDM,984,RC,11730,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,0.792,other,Not separately reimbursable,,31.95,,0.792,other,Not separately reimbursable,51.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,27.968,other,Not separately reimbursable,,,,0.992,other,Not separately reimbursable,2071.94,3723,
Tangntl bx skin single les,4050228,CDM,984,RC,11102,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,104.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.656,other,Not separately reimbursable,,31.95,,2.656,other,Not separately reimbursable,35.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,93.632,other,Not separately reimbursable,,,,3.328,other,Not separately reimbursable,2072.94,3724,
"TANGENTIAL BIOPSY SKIN, EACH ADDL LESION",4050229,CDM,984,RC,11103,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,56.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.224,other,Not separately reimbursable,,31.95,,18.224,other,Not separately reimbursable,20.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.472,other,Not separately reimbursable,,,,22.816,other,Not separately reimbursable,2073.94,3725,
29445 APPLICATION RIGID TOTAL CONTACT LEG CAST PRO FEE,4050230,CDM,984,RC,29445,HCPCS,OUTPATIENT,,,310,186,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,199.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.224,other,Not separately reimbursable,,31.95,,18.224,other,Not separately reimbursable,93.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.824,other,Not separately reimbursable,,,,22.816,other,Not separately reimbursable,2074.94,3726,
WEDGE EXCISION SKIN NAIL FOLD PRO FEE,4050231,CDM,984,RC,11765,HCPCS,OUTPATIENT,,,387,232.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.472,other,Not separately reimbursable,,31.95,,5.472,other,Not separately reimbursable,87.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.632,other,Not separately reimbursable,,,,6.848,other,Not separately reimbursable,2075.94,3727,
TX SUPERFICIAL WOUND DEHISCENCE SMPL CLOSURE PROF,4050232,CDM,984,RC,12020,HCPCS,OUTPATIENT,,,560,336,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,309.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,40.384,other,Not separately reimbursable,,31.95,,40.384,other,Not separately reimbursable,177.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,50.56,other,Not separately reimbursable,2076.94,3728,
SURGIGRAFT PER SQ CM PRO FEE,4050233,CDM,984,RC,Q4183,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.064,other,Not separately reimbursable,,31.95,,19.064,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,4.256,other,Not separately reimbursable,,,,23.872,other,Not separately reimbursable,2077.94,3729,
NEG PRESS WND TX NON DME </=50 SQ CM PROF,4050234,CDM,984,RC,97607,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,149.448,other,Not separately reimbursable,,31.95,,149.448,other,Not separately reimbursable,20.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,187.104,other,Not separately reimbursable,2078.94,3730,
SKIN SUB GRAFT T/A/L 100SCM/<1ST 25 PROF,4050235,CDM,984,RC,15271,HCPCS,OUTPATIENT,,,253,151.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,157.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,31.832,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,79.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.848,other,Not separately reimbursable,,,,28.936,other,Not separately reimbursable,2079.94,3731,
SKIN SUB GRAFT T/A/L ADDL  PROF,4050236,CDM,984,RC,15272,HCPCS,OUTPATIENT,,,45,27,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,29.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.896,other,Not separately reimbursable,,31.95,,8.896,other,Not separately reimbursable,16.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.344,other,Not separately reimbursable,,,,11.136,other,Not separately reimbursable,2080.94,3732,
SKIN SUB GRAFT T/ARM/LG CHILD 1ST PROF,4050237,CDM,984,RC,15273,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,336.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,9.176,other,Not separately reimbursable,,31.95,,9.176,other,Not separately reimbursable,184.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.344,other,Not separately reimbursable,,,,11.488,other,Not separately reimbursable,2081.94,3733,
SKIN SUB GRAFT T/A/L CHILD ADDL PROF,4050238,CDM,984,RC,15274,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,82.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,122.64,other,Not separately reimbursable,,31.95,,122.64,other,Not separately reimbursable,42.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.344,other,Not separately reimbursable,,,,153.536,other,Not separately reimbursable,2082.94,3734,
SKIN SUB GRAFT FACE/NK/HF/G 1ST PROF,4050239,CDM,984,RC,15275,HCPCS,OUTPATIENT,,,235,141,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,167.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,108.608,other,Not separately reimbursable,,31.95,,108.608,other,Not separately reimbursable,88.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.712,other,Not separately reimbursable,,,,135.968,other,Not separately reimbursable,2083.94,3735,
SKIN SUB GRAFT FACE/NK/HF/G ADDL PROF,4050240,CDM,984,RC,15276,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,172.176,other,Not separately reimbursable,,31.95,,172.176,other,Not separately reimbursable,23.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,215.552,other,Not separately reimbursable,2084.94,3736,
SKIN SUB GRAFT F/N/HF/G CHILD 1ST PROF,4050241,CDM,984,RC,15277,HCPCS,OUTPATIENT,,,570,342,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.112,other,Not separately reimbursable,,31.95,,5.112,other,Not separately reimbursable,210.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,6.4,other,Not separately reimbursable,2085.94,3737,
SKIN SUB GRAFT F/N/HF/G CHILD ADDL PROF,4050242,CDM,984,RC,15278,HCPCS,OUTPATIENT,,,145,87,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,,31.95,,1.28,other,Not separately reimbursable,52.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.368,other,Not separately reimbursable,,,,1.6,other,Not separately reimbursable,2086.94,3738,
WOUND PREP TRK/ARM/LEG 1ST PROF,4050262,CDM,984,RC,15002,HCPCS,OUTPATIENT,,,550,330,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,380.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,80.576,other,Not separately reimbursable,,31.95,,80.576,other,Not separately reimbursable,206.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,100.88,other,Not separately reimbursable,2087.94,3739,
WOUND PREP TRK/ARM/LEG ADDL PROF,4050263,CDM,984,RC,15003,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,81.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,26.328,other,Not separately reimbursable,,31.95,,26.328,other,Not separately reimbursable,42.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.496,other,Not separately reimbursable,,,,32.96,other,Not separately reimbursable,2088.94,3740,
WOUND PREP F/N/HF/G 1ST PROF,4050264,CDM,984,RC,15004,HCPCS,OUTPATIENT,,,650,390,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,436.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.96,other,Not separately reimbursable,,31.95,,3.96,other,Not separately reimbursable,245.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,4.96,other,Not separately reimbursable,2089.94,3741,
WOUND PREP F/N/HF/G ADDL PROF,4050265,CDM,984,RC,15005,HCPCS,OUTPATIENT,,,230,138,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.136,other,Not separately reimbursable,,31.95,,4.136,other,Not separately reimbursable,84.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,5.176,other,Not separately reimbursable,2090.94,3742,
PUNC ASP ABSCESS/HEM/BULL/CYST PROF,4050280,CDM,984,RC,10160,HCPCS,OUTPATIENT,,,276,165.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,81.112,other,Not separately reimbursable,,31.95,,81.112,other,Not separately reimbursable,90.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.24,other,Not separately reimbursable,,,,101.552,other,Not separately reimbursable,2091.94,3743,
CT Abdomen/Pelvis w + w/o Contrast,4100001,CDM,350,RC,74178,HCPCS,OUTPATIENT,,,2450,1470,TC,,,,,other,Not separately reimbursable,1319.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1319.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,861.18,35.15,,26.328,fee schedule,35.15% of LA custom fee schedule,782.78,31.95,,26.328,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,20.48,case rate,pays based on per visit rate,782.78,31.95,,32.96,Fee Schedule,31.95% of LA custom fee schedule,2092.94,3744,
Report,4100001,CDM,972,RC,74178,HCPCS,OUTPATIENT,,,302,181.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,451.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,268.384,other,Not separately reimbursable,,31.95,,268.384,other,Not separately reimbursable,224.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.48,other,Not separately reimbursable,,,,336,other,Not separately reimbursable,2093.94,3745,
CT Abdomen/Pelvis w + w/o Contrast,4100001,CDM,350,RC,74178,HCPCS,OUTPATIENT,,,2450,1470,TC,,,,,other,Not separately reimbursable,1319.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1319.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,861.18,35.15,,268.384,fee schedule,35.15% of LA custom fee schedule,782.78,31.95,,268.384,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,20.48,case rate,pays based on per visit rate,782.78,31.95,,336,Fee Schedule,31.95% of LA custom fee schedule,2094.94,3746,
CT Abdomen/Pelvis w + w/o Contrast Profee,4100001,CDM,972,RC,74178,HCPCS,OUTPATIENT,,,302,181.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,451.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,373.176,other,Not separately reimbursable,,31.95,,373.176,other,Not separately reimbursable,224.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.672,other,Not separately reimbursable,,,,467.2,other,Not separately reimbursable,2095.94,3747,
CT Abdomen/Pelvis w/o Contrast,4100002,CDM,350,RC,74176,HCPCS,OUTPATIENT,,,1600,960,TC,,,,,other,Not separately reimbursable,745.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,745.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,562.4,35.15,,33.232,fee schedule,35.15% of LA custom fee schedule,511.2,31.95,,33.232,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.256,case rate,pays based on per visit rate,511.2,31.95,,41.6,Fee Schedule,31.95% of LA custom fee schedule,2096.94,3748,
Report,4100002,CDM,972,RC,74176,HCPCS,OUTPATIENT,,,262,157.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,255.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,33.232,other,Not separately reimbursable,,31.95,,33.232,other,Not separately reimbursable,93.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.64,other,Not separately reimbursable,,,,41.6,other,Not separately reimbursable,2097.94,3749,
CT Abdomen/Pelvis w/o Contrast,4100002,CDM,350,RC,74176,HCPCS,OUTPATIENT,,,1600,960,TC,,,,,other,Not separately reimbursable,745.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,745.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,562.4,35.15,,7.16,fee schedule,35.15% of LA custom fee schedule,511.2,31.95,,7.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,20.48,case rate,pays based on per visit rate,511.2,31.95,,8.96,Fee Schedule,31.95% of LA custom fee schedule,2098.94,3750,
CT Abdomen/Pelvis w/o Contrast Profee,4100002,CDM,972,RC,74176,HCPCS,OUTPATIENT,,,262,157.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,255.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.424,other,Not separately reimbursable,,31.95,,10.424,other,Not separately reimbursable,93.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.672,other,Not separately reimbursable,,,,13.048,other,Not separately reimbursable,2099.94,3751,
Report,4100003,CDM,972,RC,74170,HCPCS,OUTPATIENT,,,209,125.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,336.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.136,other,Not separately reimbursable,,31.95,,6.136,other,Not separately reimbursable,179.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.16,other,Not separately reimbursable,,,,7.68,other,Not separately reimbursable,2100.94,3752,
CT Abdomen w/ + w/o Contrast,4100003,CDM,350,RC,74170,HCPCS,OUTPATIENT,,,1337,802.2,26,,,,,other,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,469.96,35.15,,255.6,fee schedule,35.15% of LA custom fee schedule,427.17,31.95,,255.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.128,case rate,pays based on per visit rate,427.17,31.95,,320,Fee Schedule,31.95% of LA custom fee schedule,2101.94,3753,
CT Abdomen w/ + w/o Contrast - Report BCE,4100003,CDM,350,RC,74170,HCPCS,OUTPATIENT,,,1337,802.2,26,,,,,other,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,469.96,35.15,,11.76,fee schedule,35.15% of LA custom fee schedule,427.17,31.95,,11.76,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.56,case rate,pays based on per visit rate,427.17,31.95,,14.72,Fee Schedule,31.95% of LA custom fee schedule,2102.94,3754,
CT Abdomen w/ + w/o Contrast,4100003,CDM,350,RC,74170,HCPCS,OUTPATIENT,,,1337,802.2,26,,,,,other,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,469.96,35.15,,3.336,fee schedule,35.15% of LA custom fee schedule,427.17,31.95,,3.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,24.016,case rate,pays based on per visit rate,427.17,31.95,,4.176,Fee Schedule,31.95% of LA custom fee schedule,2103.94,3755,
CT Abdomen w/ + w/o Contrast Profee,4100003,CDM,972,RC,74170,HCPCS,OUTPATIENT,,,209,125.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,336.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.904,other,Not separately reimbursable,,31.95,,6.904,other,Not separately reimbursable,179.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.632,other,Not separately reimbursable,,,,8.64,other,Not separately reimbursable,2104.94,3756,
Report,4100004,CDM,972,RC,74160,HCPCS,OUTPATIENT,,,190,114,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,298.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,911.216,other,Not separately reimbursable,,31.95,,911.216,other,Not separately reimbursable,158.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,27.664,other,Not separately reimbursable,,,,1140.8,other,Not separately reimbursable,2105.94,3757,
CT Abdomen w/ Contrast,4100004,CDM,350,RC,74160,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,790.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,790.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,594.272,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,594.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,14.616,case rate,pays based on per visit rate,383.4,31.95,,744,Fee Schedule,31.95% of LA custom fee schedule,2106.94,3758,
CT Abdomen w/ Contrast,4100004,CDM,350,RC,74160,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,790.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,790.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,14.312,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,14.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.992,case rate,pays based on per visit rate,383.4,31.95,,17.92,Fee Schedule,31.95% of LA custom fee schedule,2107.94,3759,
CT Abdomen w/ Contrast Profee,4100004,CDM,972,RC,74160,HCPCS,OUTPATIENT,,,190,114,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,298.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.424,other,Not separately reimbursable,,31.95,,10.424,other,Not separately reimbursable,158.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.16,other,Not separately reimbursable,,,,13.048,other,Not separately reimbursable,2108.94,3760,
Report,4100005,CDM,972,RC,74150,HCPCS,OUTPATIENT,,,178,106.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,189.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.248,other,Not separately reimbursable,,31.95,,11.248,other,Not separately reimbursable,74.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.384,other,Not separately reimbursable,,,,14.08,other,Not separately reimbursable,2109.94,3761,
CT Abdomen w/o Contrast,4100005,CDM,350,RC,74150,HCPCS,OUTPATIENT,,,800,480,26,,,,,other,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,3.256,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,3.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.256,case rate,pays based on per visit rate,255.6,31.95,,4.08,Fee Schedule,31.95% of LA custom fee schedule,2110.94,3762,
CT Abdomen w/o Contrast,4100005,CDM,350,RC,74150,HCPCS,OUTPATIENT,,,800,480,26,,,,,other,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.864,case rate,pays based on per visit rate,255.6,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,2111.94,3763,
CT Abdomen w/o Contrast Profee,4100005,CDM,972,RC,74150,HCPCS,OUTPATIENT,,,178,106.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,189.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.832,other,Not separately reimbursable,,31.95,,3.832,other,Not separately reimbursable,74.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.336,other,Not separately reimbursable,,,,4.8,other,Not separately reimbursable,2112.94,3764,
CT Abdomen w/o Cont,4100005,CDM,350,RC,74150,HCPCS,OUTPATIENT,,,800,480,26,,,,,other,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,215.216,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,215.216,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.336,case rate,pays based on per visit rate,255.6,31.95,,269.44,Fee Schedule,31.95% of LA custom fee schedule,2113.94,3765,
CT Angiography Head,4100006,CDM,351,RC,70496,HCPCS,OUTPATIENT,,,1100,660,TC,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,189.144,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,189.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.336,case rate,pays based on per visit rate,351.45,31.95,,236.8,Fee Schedule,31.95% of LA custom fee schedule,2114.94,3766,
Report,4100006,CDM,972,RC,70496,HCPCS,OUTPATIENT,,,263,157.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,360.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,189.144,other,Not separately reimbursable,,31.95,,189.144,other,Not separately reimbursable,177.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.168,other,Not separately reimbursable,,,,236.8,other,Not separately reimbursable,2115.94,3767,
CT Angiography Head w/ Contrast,4100006,CDM,351,RC,70496,HCPCS,OUTPATIENT,,,1100,660,TC,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,184.032,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,184.032,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,17.632,case rate,pays based on per visit rate,351.45,31.95,,230.4,Fee Schedule,31.95% of LA custom fee schedule,2116.94,3768,
CT Angiography Head w/ Contrast Profee,4100006,CDM,972,RC,70496,HCPCS,OUTPATIENT,,,262,157.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,360.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,27.608,other,Not separately reimbursable,,31.95,,27.608,other,Not separately reimbursable,177.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.952,other,Not separately reimbursable,,,,34.56,other,Not separately reimbursable,2117.94,3769,
Report,4100007,CDM,972,RC,73706,HCPCS,OUTPATIENT,,,282,169.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,369.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,174.832,other,Not separately reimbursable,,31.95,,174.832,other,Not separately reimbursable,214.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,218.88,other,Not separately reimbursable,2118.94,3770,
CT Angiography Lower Extremity Bilat Profee,4100007,CDM,972,RC,73706,HCPCS,OUTPATIENT,,,282,169.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,369.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,51.12,other,Not separately reimbursable,,31.95,,51.12,other,Not separately reimbursable,214.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.952,other,Not separately reimbursable,,,,64,other,Not separately reimbursable,2119.94,3771,
Report,4100008,CDM,972,RC,73706,HCPCS,OUTPATIENT,,,282,169.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,369.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,61.344,other,Not separately reimbursable,,31.95,,61.344,other,Not separately reimbursable,214.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.544,other,Not separately reimbursable,,,,76.8,other,Not separately reimbursable,2120.94,3772,
CT Angiography Lower Extremity Bilat,4100008,CDM,352,RC,73706,HCPCS,OUTPATIENT,,,1355,813,26,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,17.384,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,17.384,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,23.408,case rate,pays based on per visit rate,432.92,31.95,,21.76,Fee Schedule,31.95% of LA custom fee schedule,2121.94,3773,
CT Angiography Lower Extremity Left,4100008,CDM,352,RC,73706,HCPCS,OUTPATIENT,,,1355,813,26,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,1.792,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,1.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,27.36,case rate,pays based on per visit rate,432.92,31.95,,2.24,Fee Schedule,31.95% of LA custom fee schedule,2122.94,3774,
Report,4100009,CDM,972,RC,73706,HCPCS,OUTPATIENT,,,282,169.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,369.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.672,other,Not separately reimbursable,,31.95,,7.672,other,Not separately reimbursable,214.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.656,other,Not separately reimbursable,,,,9.6,other,Not separately reimbursable,2123.94,3775,
CT Angiography Lower Extremity Right,4100009,CDM,352,RC,73706,HCPCS,OUTPATIENT,,,1355,813,26,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,7.672,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,7.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,12.16,case rate,pays based on per visit rate,432.92,31.95,,9.6,Fee Schedule,31.95% of LA custom fee schedule,2124.94,3776,
FMC CT Angiography Lower Extremity Right,4100009,CDM,352,RC,73706,HCPCS,OUTPATIENT,,,1355,813,26,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.64,case rate,pays based on per visit rate,432.92,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2125.94,3777,
CT Angiography Neck,4100010,CDM,350,RC,70498,HCPCS,OUTPATIENT,,,1100,660,TC,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,8.432,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,8.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.64,case rate,pays based on per visit rate,351.45,31.95,,10.56,Fee Schedule,31.95% of LA custom fee schedule,2126.94,3778,
Report,4100010,CDM,972,RC,70498,HCPCS,OUTPATIENT,,,262,157.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,360.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.432,other,Not separately reimbursable,,31.95,,8.432,other,Not separately reimbursable,176.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,10.56,other,Not separately reimbursable,2127.94,3779,
CT Angiography Neck,4100010,CDM,350,RC,70498,HCPCS,OUTPATIENT,,,1100,660,TC,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,8.432,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,8.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.64,case rate,pays based on per visit rate,351.45,31.95,,10.56,Fee Schedule,31.95% of LA custom fee schedule,2128.94,3780,
FMC CT Angiography Neck Profee,4100010,CDM,972,RC,70498,HCPCS,OUTPATIENT,,,263,157.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,360.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.432,other,Not separately reimbursable,,31.95,,8.432,other,Not separately reimbursable,176.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,10.56,other,Not separately reimbursable,2129.94,3781,
Report,4100011,CDM,972,RC,73206,HCPCS,OUTPATIENT,,,269,161.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,363.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.432,other,Not separately reimbursable,,31.95,,8.432,other,Not separately reimbursable,194.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.64,other,Not separately reimbursable,,,,10.56,other,Not separately reimbursable,2130.94,3782,
CT Angiography Upper Extremity Bilat,4100011,CDM,352,RC,73206,HCPCS,OUTPATIENT,,,1100,660,26,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,8.432,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,8.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.032,case rate,pays based on per visit rate,351.45,31.95,,10.56,Fee Schedule,31.95% of LA custom fee schedule,2131.94,3783,
Report,4100012,CDM,972,RC,73206,HCPCS,OUTPATIENT,,,269,161.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,363.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,24.024,other,Not separately reimbursable,,31.95,,24.024,other,Not separately reimbursable,194.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,30.08,other,Not separately reimbursable,2132.94,3784,
CT Angiography Upper Extremity Left,4100012,CDM,352,RC,73206,HCPCS,OUTPATIENT,,,1100,660,26,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,24.024,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,24.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,13.072,case rate,pays based on per visit rate,351.45,31.95,,30.08,Fee Schedule,31.95% of LA custom fee schedule,2133.94,3785,
Report,4100013,CDM,972,RC,73206,HCPCS,OUTPATIENT,,,269,161.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,363.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,24.024,other,Not separately reimbursable,,31.95,,24.024,other,Not separately reimbursable,194.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.072,other,Not separately reimbursable,,,,30.08,other,Not separately reimbursable,2134.94,3786,
CT Angiography Upper Extremity Right,4100013,CDM,352,RC,73206,HCPCS,OUTPATIENT,,,1100,660,26,,,,,other,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,24.024,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,24.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,13.072,case rate,pays based on per visit rate,351.45,31.95,,30.08,Fee Schedule,31.95% of LA custom fee schedule,2135.94,3787,
Report,4100014,CDM,972,RC,72127,HCPCS,OUTPATIENT,,,189,113.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.304,other,Not separately reimbursable,,31.95,,2.304,other,Not separately reimbursable,126.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.376,other,Not separately reimbursable,,,,2.88,other,Not separately reimbursable,2136.94,3788,
CT Spine Cervical w/ + w/o Contrast,4100014,CDM,350,RC,72127,HCPCS,OUTPATIENT,,,1650,990,26,,,,,other,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,13.072,case rate,pays based on per visit rate,527.18,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,2137.94,3789,
Report,4100015,CDM,972,RC,72126,HCPCS,OUTPATIENT,,,183,109.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,284.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,24.024,other,Not separately reimbursable,,31.95,,24.024,other,Not separately reimbursable,102.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.728,other,Not separately reimbursable,,,,30.08,other,Not separately reimbursable,2138.94,3790,
CT Spine Cervical w/ Contrast,4100015,CDM,350,RC,72126,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.64,case rate,pays based on per visit rate,383.4,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,2139.94,3791,
CT Chest W/WO Contrast,4100016,CDM,350,RC,71270,HCPCS,OUTPATIENT,,,1337,802.2,TC,,,,,other,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,469.96,35.15,,24.024,fee schedule,35.15% of LA custom fee schedule,427.17,31.95,,24.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.032,case rate,pays based on per visit rate,427.17,31.95,,30.08,Fee Schedule,31.95% of LA custom fee schedule,2140.94,3792,
Report,4100016,CDM,972,RC,71270,HCPCS,OUTPATIENT,,,206,123.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.904,other,Not separately reimbursable,,31.95,,6.904,other,Not separately reimbursable,125.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,8.64,other,Not separately reimbursable,2141.94,3793,
FMC CT Chest w/ + w/o Cont,4100016,CDM,350,RC,71270,HCPCS,OUTPATIENT,,,1337,802.2,TC,,,,,other,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,469.96,35.15,,24.024,fee schedule,35.15% of LA custom fee schedule,427.17,31.95,,24.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,3.04,case rate,pays based on per visit rate,427.17,31.95,,30.08,Fee Schedule,31.95% of LA custom fee schedule,2142.94,3794,
FMC CT Chest w/ + w/o Cont Profee,4100016,CDM,972,RC,71270,HCPCS,OUTPATIENT,,,206,123.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.448,other,Not separately reimbursable,,31.95,,3.448,other,Not separately reimbursable,125.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.296,other,Not separately reimbursable,,,,4.32,other,Not separately reimbursable,2143.94,3795,
FMC CT Chest w/ + w/o Cont Profee,4100016,CDM,972,RC,71260,HCPCS,OUTPATIENT,,,206,123.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,246.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.008,other,Not separately reimbursable,,31.95,,23.008,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.296,other,Not separately reimbursable,,,,28.8,other,Not separately reimbursable,2144.94,3796,
CT Chest W/Contrast,4100017,CDM,350,RC,71260,HCPCS,OUTPATIENT,,,1200,720,TC,,,,,other,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,5.624,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,5.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.208,case rate,pays based on per visit rate,383.4,31.95,,7.04,Fee Schedule,31.95% of LA custom fee schedule,2145.94,3797,
Report,4100017,CDM,972,RC,71260,HCPCS,OUTPATIENT,,,186,111.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,246.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.008,other,Not separately reimbursable,,31.95,,23.008,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,28.8,other,Not separately reimbursable,2146.94,3798,
FMC CT Chest w/ Cont,4100017,CDM,350,RC,71260,HCPCS,OUTPATIENT,,,1200,720,TC,,,,,other,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.208,case rate,pays based on per visit rate,383.4,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,2147.94,3799,
FMC CT Chest w/ Cont Profee,4100017,CDM,972,RC,71260,HCPCS,OUTPATIENT,,,186,111.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,246.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.008,other,Not separately reimbursable,,31.95,,23.008,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.816,other,Not separately reimbursable,,,,28.8,other,Not separately reimbursable,2148.94,3800,
CT Chest W/O Contrast,4100018,CDM,350,RC,71250,HCPCS,OUTPATIENT,,,800,480,TC,,,,,other,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,2.936,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,2.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.816,case rate,pays based on per visit rate,255.6,31.95,,3.68,Fee Schedule,31.95% of LA custom fee schedule,2149.94,3801,
Report,4100018,CDM,972,RC,71250,HCPCS,OUTPATIENT,,,153,91.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.008,other,Not separately reimbursable,,31.95,,23.008,other,Not separately reimbursable,75.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,28.8,other,Not separately reimbursable,2150.94,3802,
FMC CT Chest w/o Cont,4100018,CDM,350,RC,71250,HCPCS,OUTPATIENT,,,800,480,TC,,,,,other,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,3.832,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,3.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.512,case rate,pays based on per visit rate,255.6,31.95,,4.8,Fee Schedule,31.95% of LA custom fee schedule,2151.94,3803,
FMC CT Chest w/o Cont Profee,4100018,CDM,972,RC,71250,HCPCS,OUTPATIENT,,,153,91.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.344,other,Not separately reimbursable,,31.95,,4.344,other,Not separately reimbursable,75.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,5.44,other,Not separately reimbursable,2152.94,3804,
CT Chest/Abdomen w/Cont,4100019,CDM,350,RC,74177,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,1013.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1013.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,28.576,case rate,pays based on per visit rate,383.4,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2153.94,3805,
Ct Chest /Abdomen/Pelvis w/o Cont ProFee,4100019,CDM,972,RC,74177,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,399.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.624,other,Not separately reimbursable,,31.95,,5.624,other,Not separately reimbursable,190,100,,,fee schedule,100% of CMS physician fee schedule,,,,16.72,other,Not separately reimbursable,,,,7.04,other,Not separately reimbursable,2154.94,3806,
CT Chest/Abdomen w/o Contrast,4100021,CDM,350,RC,74150,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,36.48,case rate,pays based on per visit rate,255.6,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2155.94,3807,
CT Chest/Abdomen w/o Contrast ProFee,4100021,CDM,972,RC,71250,HCPCS,OUTPATIENT,,,153,91.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.064,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,75.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.904,other,Not separately reimbursable,,,,3.84,other,Not separately reimbursable,2156.94,3808,
Ct Chest /Abdomen/Pelvis w/o Cont,4100022,CDM,350,RC,74176,HCPCS,OUTPATIENT,,,1600,960,TC,,,,,other,Not separately reimbursable,745.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,745.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,562.4,35.15,,28.88,fee schedule,35.15% of LA custom fee schedule,511.2,31.95,,28.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.432,case rate,pays based on per visit rate,511.2,31.95,,36.16,Fee Schedule,31.95% of LA custom fee schedule,2157.94,3809,
CT Chest/Abd/Pel w/ Contrast,4100023,CDM,350,RC,1-71260|2-,HCPCS,OUTPATIENT,,,3150,1890,TC,,,,,other,Not separately reimbursable,1575,50,,1260,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1575,50,,1260,percent of total billed charges,50% of total billed charges,1107.23,35.15,,3.064,percent of total billed charges,35.15% of total billed charges,102.56,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,525,100,,2.344,case rate,pays based on per visit rate,1006.43,31.95,,3.84,percent of total billed charges,31.95% of total billed charges,2158.94,3810,
Report,4100023,CDM,972,RC,71260,HCPCS,OUTPATIENT,,,186,111.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,246.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,28.88,other,Not separately reimbursable,,31.95,,28.88,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,82.08,other,Not separately reimbursable,,,,36.16,other,Not separately reimbursable,2159.94,3811,
CT Chest/Abd/Pel w/o Contrast,4100024,CDM,350,RC,1-71250|2-,HCPCS,OUTPATIENT,,,2400,1440,TC,,,,,other,Not separately reimbursable,1200,50,,960,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1200,50,,960,percent of total billed charges,50% of total billed charges,843.6,35.15,,6.904,percent of total billed charges,35.15% of total billed charges,104.48,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,525,100,,2.128,case rate,pays based on per visit rate,766.8,31.95,,8.64,percent of total billed charges,31.95% of total billed charges,2160.94,3812,
Report,4100024,CDM,972,RC,1-71250|2-,HCPCS,OUTPATIENT,,,,,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,28.88,other,Not separately reimbursable,,31.95,,28.88,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,4.864,other,Not separately reimbursable,,,,36.16,other,Not separately reimbursable,2161.94,3813,
CT Guided Needle Placement,4100025,CDM,350,RC,77012,HCPCS,OUTPATIENT,,,1185,711,TC,,,,,other,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,416.53,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,378.61,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.56,case rate,pays based on per visit rate,378.61,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,2162.94,3814,
Report,4100025,CDM,972,RC,77012,HCPCS,OUTPATIENT,,,172,103.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,28.88,other,Not separately reimbursable,,31.95,,28.88,other,Not separately reimbursable,62.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,36.16,other,Not separately reimbursable,2163.94,3815,
Report,4100026,CDM,972,RC,70470,HCPCS,OUTPATIENT,,,190,114,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,240.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.936,other,Not separately reimbursable,,31.95,,2.936,other,Not separately reimbursable,104.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,3.68,other,Not separately reimbursable,2164.94,3816,
CT Head or Brain w/ + w/o Contrast,4100026,CDM,350,RC,70470,HCPCS,OUTPATIENT,,,1337,802.2,26,,,,,other,Not separately reimbursable,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,469.96,35.15,,28.88,fee schedule,35.15% of LA custom fee schedule,427.17,31.95,,28.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.56,case rate,pays based on per visit rate,427.17,31.95,,36.16,Fee Schedule,31.95% of LA custom fee schedule,2165.94,3817,
Report,4100027,CDM,972,RC,70460,HCPCS,OUTPATIENT,,,169,101.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,206.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.432,other,Not separately reimbursable,,31.95,,2.432,other,Not separately reimbursable,87.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,22.496,other,Not separately reimbursable,,,,3.04,other,Not separately reimbursable,2166.94,3818,
CT Head or Brain w/ Contrast,4100027,CDM,350,RC,70460,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,28.88,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,28.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,19.104,case rate,pays based on per visit rate,383.4,31.95,,36.16,Fee Schedule,31.95% of LA custom fee schedule,2167.94,3819,
Report,4100028,CDM,972,RC,70450,HCPCS,OUTPATIENT,,,127,76.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.832,other,Not separately reimbursable,,31.95,,3.832,other,Not separately reimbursable,60.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.16,other,Not separately reimbursable,,,,4.8,other,Not separately reimbursable,2168.94,3820,
CT Head or Brain w/o Contrast,4100028,CDM,351,RC,70450,HCPCS,OUTPATIENT,,,800,480,26,,,,,other,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,28.88,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,28.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,12.16,case rate,pays based on per visit rate,255.6,31.95,,36.16,Fee Schedule,31.95% of LA custom fee schedule,2169.94,3821,
CT Stroke Study,4100028,CDM,351,RC,70450,HCPCS,OUTPATIENT,,,800,480,26,,,,,other,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,2.432,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,2.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,11.992,case rate,pays based on per visit rate,255.6,31.95,,3.04,Fee Schedule,31.95% of LA custom fee schedule,2170.94,3822,
ProFee CT Stroke Study,4100028,CDM,972,RC,70450,HCPCS,OUTPATIENT,,,127,76.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.432,other,Not separately reimbursable,,31.95,,2.432,other,Not separately reimbursable,60.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,3.04,other,Not separately reimbursable,2171.94,3823,
Report,4100029,CDM,972,RC,73701,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,282.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.344,other,Not separately reimbursable,,31.95,,4.344,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,5.44,other,Not separately reimbursable,2172.94,3824,
CT Lower Extremity w/ Contrast Bilateral Profee,4100029,CDM,972,RC,73701,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,282.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.936,other,Not separately reimbursable,,31.95,,2.936,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,3.68,other,Not separately reimbursable,2173.94,3825,
Report,4100030,CDM,972,RC,73701,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,282.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.936,other,Not separately reimbursable,,31.95,,2.936,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.384,other,Not separately reimbursable,,,,3.68,other,Not separately reimbursable,2174.94,3826,
CT Lower Extremity w/ Contrast Left,4100030,CDM,350,RC,73701,HCPCS,OUTPATIENT,,,1250,750,26,,,,,other,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,439.38,35.15,,4.728,fee schedule,35.15% of LA custom fee schedule,399.38,31.95,,4.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.688,case rate,pays based on per visit rate,399.38,31.95,,5.92,Fee Schedule,31.95% of LA custom fee schedule,2175.94,3827,
CT Lower Extremity w/ Contrast Bilateral,4100030,CDM,350,RC,73701,HCPCS,OUTPATIENT,,,1250,750,26,,,,,other,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,439.38,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,399.38,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.384,case rate,pays based on per visit rate,399.38,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,2176.94,3828,
Report,4100031,CDM,972,RC,73701,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,282.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.68,other,Not separately reimbursable,,31.95,,2.68,other,Not separately reimbursable,102.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,3.36,other,Not separately reimbursable,2177.94,3829,
CT Lower Extremity w/ Contrast Right,4100031,CDM,350,RC,73701,HCPCS,OUTPATIENT,,,1250,750,26,,,,,other,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,439.38,35.15,,4.856,fee schedule,35.15% of LA custom fee schedule,399.38,31.95,,4.856,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.688,case rate,pays based on per visit rate,399.38,31.95,,6.08,Fee Schedule,31.95% of LA custom fee schedule,2178.94,3830,
FMC CT Lower Extremity w/ Contrast Right,4100031,CDM,350,RC,73701,HCPCS,OUTPATIENT,,,1250,750,26,,,,,other,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,439.38,35.15,,3.96,fee schedule,35.15% of LA custom fee schedule,399.38,31.95,,3.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.688,case rate,pays based on per visit rate,399.38,31.95,,4.96,Fee Schedule,31.95% of LA custom fee schedule,2179.94,3831,
Report,4100032,CDM,972,RC,73700,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.856,other,Not separately reimbursable,,31.95,,4.856,other,Not separately reimbursable,75.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,6.08,other,Not separately reimbursable,2180.94,3832,
CT Lower Extremity w/o Contrast Bilateral Profee,4100032,CDM,972,RC,73700,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.368,other,Not separately reimbursable,,31.95,,5.368,other,Not separately reimbursable,75.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.272,other,Not separately reimbursable,,,,6.72,other,Not separately reimbursable,2181.94,3833,
Report,4100033,CDM,972,RC,73700,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.368,other,Not separately reimbursable,,31.95,,5.368,other,Not separately reimbursable,75.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.784,other,Not separately reimbursable,,,,6.72,other,Not separately reimbursable,2182.94,3834,
CT Lower Extremity w/o Contrast Left,4100033,CDM,350,RC,73700,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,2.304,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,2.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,10.64,case rate,pays based on per visit rate,383.4,31.95,,2.88,Fee Schedule,31.95% of LA custom fee schedule,2183.94,3835,
CT Lower Extremity w/o Contrast Bilat,4100033,CDM,350,RC,73700,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,2.936,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,2.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.272,case rate,pays based on per visit rate,383.4,31.95,,3.68,Fee Schedule,31.95% of LA custom fee schedule,2184.94,3836,
Report,4100034,CDM,972,RC,73700,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.936,other,Not separately reimbursable,,31.95,,2.936,other,Not separately reimbursable,75.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.272,other,Not separately reimbursable,,,,3.68,other,Not separately reimbursable,2185.94,3837,
CT Lower Extremity w/o Contrast Right,4100034,CDM,350,RC,73700,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,4.344,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,4.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.272,case rate,pays based on per visit rate,383.4,31.95,,5.44,Fee Schedule,31.95% of LA custom fee schedule,2186.94,3838,
FMC CT Lower Extremity w/o Contrast Right,4100034,CDM,350,RC,73700,HCPCS,OUTPATIENT,,,1200,720,26,,,,,other,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,1.792,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,1.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,21.28,case rate,pays based on per visit rate,383.4,31.95,,2.24,Fee Schedule,31.95% of LA custom fee schedule,2187.94,3839,
Report,4100035,CDM,972,RC,72133,HCPCS,OUTPATIENT,,,190,114,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,328.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.728,other,Not separately reimbursable,,31.95,,4.728,other,Not separately reimbursable,126.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.248,other,Not separately reimbursable,,,,5.92,other,Not separately reimbursable,2188.94,3840,
CT Spine Lumbar w/ + w/o Contrast,4100035,CDM,350,RC,72133,HCPCS,OUTPATIENT,,,1475,885,26,1253.75,85,,1003,Percent of total billed charges,85% of total billed charges,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,518.46,35.15,,4.216,fee schedule,35.15% of LA custom fee schedule,471.26,31.95,,4.216,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,13.04,case rate,pays based on per visit rate,471.26,31.95,,5.28,Fee Schedule,31.95% of LA custom fee schedule,2189.94,3841,
Report,4100036,CDM,972,RC,72132,HCPCS,OUTPATIENT,,,183,109.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,284.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.344,other,Not separately reimbursable,,31.95,,4.344,other,Not separately reimbursable,102.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.04,other,Not separately reimbursable,,,,5.44,other,Not separately reimbursable,2190.94,3842,
CT Spine Lumbar w/ Contrast,4100036,CDM,350,RC,72132,HCPCS,OUTPATIENT,,,1200,720,26,1020,85,,816,Percent of total billed charges,85% of total billed charges,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,4.728,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,4.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,11.4,case rate,pays based on per visit rate,383.4,31.95,,5.92,Fee Schedule,31.95% of LA custom fee schedule,2191.94,3843,
Report,4100037,CDM,972,RC,72131,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.904,other,Not separately reimbursable,,31.95,,6.904,other,Not separately reimbursable,75.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.416,other,Not separately reimbursable,,,,8.64,other,Not separately reimbursable,2192.94,3844,
CT Spine Lumbar w/o Contrast,4100037,CDM,350,RC,72131,HCPCS,OUTPATIENT,,,900,540,26,765,85,,612,Percent of total billed charges,85% of total billed charges,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,5.88,fee schedule,35.15% of LA custom fee schedule,287.55,31.95,,5.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,3.344,case rate,pays based on per visit rate,287.55,31.95,,7.36,Fee Schedule,31.95% of LA custom fee schedule,2193.94,3845,
Report,4100038,CDM,972,RC,70488,HCPCS,OUTPATIENT,,,189,113.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,255.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.304,other,Not separately reimbursable,,31.95,,2.304,other,Not separately reimbursable,114.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.128,other,Not separately reimbursable,,,,2.88,other,Not separately reimbursable,2194.94,3846,
CT Maxillofacial w/ + w/o Contrast,4100038,CDM,350,RC,70488,HCPCS,OUTPATIENT,,,1200,720,26,1020,85,,816,Percent of total billed charges,85% of total billed charges,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,3.648,case rate,pays based on per visit rate,383.4,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,2195.94,3847,
Report,4100039,CDM,972,RC,70487,HCPCS,OUTPATIENT,,,169,101.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,210.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.216,other,Not separately reimbursable,,31.95,,4.216,other,Not separately reimbursable,90.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.336,other,Not separately reimbursable,,,,5.28,other,Not separately reimbursable,2196.94,3848,
CT Maxillofacial w/ Contrast,4100039,CDM,350,RC,70487,HCPCS,OUTPATIENT,,,1200,720,26,1020,85,,816,Percent of total billed charges,85% of total billed charges,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,5.496,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,5.496,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.512,case rate,pays based on per visit rate,383.4,31.95,,6.88,Fee Schedule,31.95% of LA custom fee schedule,2197.94,3849,
Report,4100040,CDM,972,RC,70486,HCPCS,OUTPATIENT,,,127,76.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,174.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.808,other,Not separately reimbursable,,31.95,,2.808,other,Not separately reimbursable,80.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,3.52,other,Not separately reimbursable,2198.94,3850,
CT Maxillofacial w/o Contrast,4100040,CDM,350,RC,70486,HCPCS,OUTPATIENT,,,800,480,26,680,85,,544,Percent of total billed charges,85% of total billed charges,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,4.472,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,4.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.736,case rate,pays based on per visit rate,255.6,31.95,,5.6,Fee Schedule,31.95% of LA custom fee schedule,2199.94,3851,
CT Soft Tissue Neck/Chest w/ + w/o ProFee,4100041,CDM,972,RC,71270,HCPCS,OUTPATIENT,,,206,123.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,,31.95,,2.56,other,Not separately reimbursable,125.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.968,other,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,2200.94,3852,
CT Soft Tissue Neck/Chest w/o Cont ProFee,4100043,CDM,972,RC,71250,HCPCS,OUTPATIENT,,,153,91.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.6,other,Not separately reimbursable,,31.95,,4.6,other,Not separately reimbursable,75.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,19.152,other,Not separately reimbursable,,,,5.76,other,Not separately reimbursable,2201.94,3853,
Report,4100045,CDM,972,RC,70482,HCPCS,OUTPATIENT,,,216,129.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,340.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.472,other,Not separately reimbursable,,31.95,,4.472,other,Not separately reimbursable,138.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.776,other,Not separately reimbursable,,,,5.6,other,Not separately reimbursable,2202.94,3854,
CT Orbit Sella etc. w/ + w/o Contrast,4100045,CDM,350,RC,70482,HCPCS,OUTPATIENT,,,990,594,1-26|2-LT,841.5,85,,673.2,Percent of total billed charges,85% of total billed charges,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,347.99,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,316.31,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,13.68,case rate,pays based on per visit rate,316.31,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,2203.94,3855,
Report,4100048,CDM,972,RC,70481,HCPCS,OUTPATIENT,,,206,123.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,335.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.216,other,Not separately reimbursable,,31.95,,4.216,other,Not separately reimbursable,116.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,5.28,other,Not separately reimbursable,2204.94,3856,
CT Orbit Sella etc. w/ Contrast,4100048,CDM,350,RC,70481,HCPCS,OUTPATIENT,,,890,534,1-26|2-LT,756.5,85,,605.2,Percent of total billed charges,85% of total billed charges,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,312.84,35.15,,2.048,fee schedule,35.15% of LA custom fee schedule,284.36,31.95,,2.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.688,case rate,pays based on per visit rate,284.36,31.95,,2.56,Fee Schedule,31.95% of LA custom fee schedule,2205.94,3857,
CT Bone Density Study,4100049,CDM,350,RC,77078,HCPCS,OUTPATIENT,,,240,144,TC,204,85,,163.2,Percent of total billed charges,85% of total billed charges,226.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,226.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,84.36,35.15,,2.936,fee schedule,35.15% of LA custom fee schedule,76.68,31.95,,2.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,9.12,case rate,pays based on per visit rate,76.68,31.95,,3.68,Fee Schedule,31.95% of LA custom fee schedule,2206.94,3858,
Report,4100049,CDM,972,RC,77078,HCPCS,OUTPATIENT,,,36,21.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.344,other,Not separately reimbursable,,31.95,,4.344,other,Not separately reimbursable,36,100,,,fee schedule,100% of CMS physician fee schedule,,,,24.016,other,Not separately reimbursable,,,,5.44,other,Not separately reimbursable,2207.94,3859,
Report,4100051,CDM,972,RC,70480,HCPCS,OUTPATIENT,,,191,114.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,221.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.008,other,Not separately reimbursable,,31.95,,6.008,other,Not separately reimbursable,90.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,7.52,other,Not separately reimbursable,2208.94,3860,
CT Orbit Sella etc. w/o Contrast,4100051,CDM,350,RC,70480,HCPCS,OUTPATIENT,,,520,312,1-26|2-LT,442,85,,353.6,Percent of total billed charges,85% of total billed charges,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,182.78,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,166.14,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.52,case rate,pays based on per visit rate,166.14,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,2209.94,3861,
Report,4100053,CDM,972,RC,72194,HCPCS,OUTPATIENT,,,182,109.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.064,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,178.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,3.84,other,Not separately reimbursable,2210.94,3862,
CT Pelvis w/ + w/o Contrast,4100053,CDM,350,RC,72194,HCPCS,OUTPATIENT,,,1337,802.2,26,1136.45,85,,909.16,Percent of total billed charges,85% of total billed charges,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,469.96,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,427.17,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,3.344,case rate,pays based on per visit rate,427.17,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,2211.94,3863,
Report,4100054,CDM,972,RC,72193,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,291.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.224,other,Not separately reimbursable,,31.95,,10.224,other,Not separately reimbursable,158.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.072,other,Not separately reimbursable,,,,12.8,other,Not separately reimbursable,2212.94,3864,
CT Pelvis w/ Contrast,4100054,CDM,350,RC,72193,HCPCS,OUTPATIENT,,,1200,720,26,1020,85,,816,Percent of total billed charges,85% of total billed charges,790.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,790.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,434.52,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,434.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.56,case rate,pays based on per visit rate,383.4,31.95,,544,Fee Schedule,31.95% of LA custom fee schedule,2213.94,3865,
Report,4100055,CDM,972,RC,72192,HCPCS,OUTPATIENT,,,163,97.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,183.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.624,other,Not separately reimbursable,,31.95,,5.624,other,Not separately reimbursable,75.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,7.04,other,Not separately reimbursable,2214.94,3866,
CT Pelvis w/o Contrast,4100055,CDM,350,RC,72192,HCPCS,OUTPATIENT,,,800,480,26,680,85,,544,Percent of total billed charges,85% of total billed charges,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,5.368,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,5.368,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,1.216,case rate,pays based on per visit rate,255.6,31.95,,6.72,Fee Schedule,31.95% of LA custom fee schedule,2215.94,3867,
Report,4100056,CDM,972,RC,70492,HCPCS,OUTPATIENT,,,216,129.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,307.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.024,other,Not separately reimbursable,,31.95,,1.024,other,Not separately reimbursable,133.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,25.84,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,2216.94,3868,
CT Soft Tissue Neck w/ + w/o Contrast,4100056,CDM,350,RC,70492,HCPCS,OUTPATIENT,,,1425,855,26,1211.25,85,,969,Percent of total billed charges,85% of total billed charges,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,500.89,35.15,,1.792,fee schedule,35.15% of LA custom fee schedule,455.29,31.95,,1.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,7.904,case rate,pays based on per visit rate,455.29,31.95,,2.24,Fee Schedule,31.95% of LA custom fee schedule,2217.94,3869,
CT Soft Tissue Neck w/ + w/o Contrast,4100056,CDM,350,RC,70492,HCPCS,OUTPATIENT,,,1425,855,26,1211.25,85,,969,Percent of total billed charges,85% of total billed charges,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,816.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,500.89,35.15,,10.736,fee schedule,35.15% of LA custom fee schedule,455.29,31.95,,10.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,11.856,case rate,pays based on per visit rate,455.29,31.95,,13.44,Fee Schedule,31.95% of LA custom fee schedule,2218.94,3870,
CT Soft Tissue Neck w/ + w/o Contrast Profee,4100056,CDM,972,RC,70492,HCPCS,OUTPATIENT,,,216,129.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,307.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,357.072,other,Not separately reimbursable,,31.95,,357.072,other,Not separately reimbursable,133.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,28.272,other,Not separately reimbursable,,,,447.04,other,Not separately reimbursable,2219.94,3871,
Report,4100057,CDM,972,RC,70491,HCPCS,OUTPATIENT,,,207,124.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,255.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.792,other,Not separately reimbursable,,31.95,,1.792,other,Not separately reimbursable,109.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.432,other,Not separately reimbursable,,,,2.24,other,Not separately reimbursable,2220.94,3872,
CT Soft Tissue Neck w/ Contrast,4100057,CDM,350,RC,70491,HCPCS,OUTPATIENT,,,1200,720,26,1020,85,,816,Percent of total billed charges,85% of total billed charges,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,45.752,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,45.752,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.432,case rate,pays based on per visit rate,383.4,31.95,,57.28,Fee Schedule,31.95% of LA custom fee schedule,2221.94,3873,
CT Soft Tissue Neck w/ Contrast,4100057,CDM,350,RC,70491,HCPCS,OUTPATIENT,,,1200,720,26,1020,85,,816,Percent of total billed charges,85% of total billed charges,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,654.25,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,421.8,35.15,,7.16,fee schedule,35.15% of LA custom fee schedule,383.4,31.95,,7.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.432,case rate,pays based on per visit rate,383.4,31.95,,8.96,Fee Schedule,31.95% of LA custom fee schedule,2222.94,3874,
CT Soft Tissue Neck w/ Contrast Profee,4100057,CDM,972,RC,70491,HCPCS,OUTPATIENT,,,207,124.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,255.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,164.864,other,Not separately reimbursable,,31.95,,164.864,other,Not separately reimbursable,109.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.432,other,Not separately reimbursable,,,,206.4,other,Not separately reimbursable,2223.94,3875,
Report,4100058,CDM,972,RC,70490,HCPCS,OUTPATIENT,,,191,114.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,208.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,,31.95,,2.56,other,Not separately reimbursable,82.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,2224.94,3876,
CT Soft Tissue Neck w/o Contrast,4100058,CDM,350,RC,70490,HCPCS,OUTPATIENT,,,800,480,26,680,85,,544,Percent of total billed charges,85% of total billed charges,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,0.512,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,0.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,11.552,case rate,pays based on per visit rate,255.6,31.95,,0.64,Fee Schedule,31.95% of LA custom fee schedule,2225.94,3877,
CT Soft Tissue Neck w/o Contrast,4100058,CDM,350,RC,70490,HCPCS,OUTPATIENT,,,800,480,26,680,85,,544,Percent of total billed charges,85% of total billed charges,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,545.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,893.32,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,893.32,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,11.552,case rate,pays based on per visit rate,255.6,31.95,,1118.4,Fee Schedule,31.95% of LA custom fee schedule,2226.94,3878,
CT Soft Tissue Neck w/o Contrast Profee,4100058,CDM,972,RC,70490,HCPCS,OUTPATIENT,,,191,114.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,208.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.68,other,Not separately reimbursable,,31.95,,19.68,other,Not separately reimbursable,82.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.504,other,Not separately reimbursable,,,,24.64,other,Not separately reimbursable,2227.94,3879,
Report,4100059,CDM,972,RC,72130,HCPCS,OUTPATIENT,,,189,113.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.848,other,Not separately reimbursable,,31.95,,15.848,other,Not separately reimbursable,127.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.384,other,Not separately reimbursable,,,,19.84,other,Not separately reimbursable,2228.94,3880,
CT Spine Thoracic w/ + w/o Contrast,4100059,CDM,350,RC,72130,HCPCS,OUTPATIENT,,,1002,601.2,26,851.7,85,,681.36,Percent of total billed charges,85% of total billed charges,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,947.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,352.2,35.15,,669.256,fee schedule,35.15% of LA custom fee schedule,320.14,31.95,,12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.432,case rate,pays based on per visit rate,320.14,31.95,,608.328,Fee Schedule,31.95% of LA custom fee schedule,2229.94,3881,
Report,4100060,CDM,972,RC,72129,HCPCS,OUTPATIENT,,,182,109.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,285.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,17.896,other,Not separately reimbursable,,31.95,,17.896,other,Not separately reimbursable,102.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,37.392,other,Not separately reimbursable,,,,22.4,other,Not separately reimbursable,2230.94,3882,
CT Spine Thoracic w/ Contrast,4100060,CDM,350,RC,72129,HCPCS,OUTPATIENT,,,964,578.4,26,819.4,85,,655.52,Percent of total billed charges,85% of total billed charges,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,338.85,35.15,,3.704,fee schedule,35.15% of LA custom fee schedule,308,31.95,,3.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,0.912,case rate,pays based on per visit rate,308,31.95,,4.64,Fee Schedule,31.95% of LA custom fee schedule,2231.94,3883,
Report,4100061,CDM,972,RC,72128,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.112,other,Not separately reimbursable,,31.95,,5.112,other,Not separately reimbursable,75.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,6.4,other,Not separately reimbursable,2232.94,3884,
CT Spine Thoracic w/o Contrast,4100061,CDM,350,RC,72128,HCPCS,OUTPATIENT,,,800,480,26,680,85,,544,Percent of total billed charges,85% of total billed charges,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,1.536,fee schedule,35.15% of LA custom fee schedule,255.6,31.95,,1.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,4.256,case rate,pays based on per visit rate,255.6,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,2233.94,3885,
Report,4100062,CDM,972,RC,73202,HCPCS,OUTPATIENT,,,183,109.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.944,other,Not separately reimbursable,,31.95,,8.944,other,Not separately reimbursable,174.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.072,other,Not separately reimbursable,,,,11.2,other,Not separately reimbursable,2234.94,3886,
CT Upper Extremity w/w/o contrast bilat Profee,4100062,CDM,972,RC,73202,HCPCS,OUTPATIENT,,,183,109.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.16,other,Not separately reimbursable,,31.95,,7.16,other,Not separately reimbursable,174.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.816,other,Not separately reimbursable,,,,8.96,other,Not separately reimbursable,2235.94,3887,
Report,4100063,CDM,972,RC,73202,HCPCS,OUTPATIENT,,,183,109.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.112,other,Not separately reimbursable,,31.95,,5.112,other,Not separately reimbursable,174.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,6.4,other,Not separately reimbursable,2236.94,3888,
CT Upper Extremity w/+w/o Contrast Bilat,4100063,CDM,350,RC,73202,HCPCS,OUTPATIENT,,,1080,648,26,918,85,,734.4,Percent of total billed charges,85% of total billed charges,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,379.62,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,345.06,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,12.768,case rate,pays based on per visit rate,345.06,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2237.94,3889,
CT Upper Extremity w/+w/o Contrast Left,4100063,CDM,350,RC,73202,HCPCS,OUTPATIENT,,,1080,648,26,918,85,,734.4,Percent of total billed charges,85% of total billed charges,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,379.62,35.15,,109.912,fee schedule,35.15% of LA custom fee schedule,345.06,31.95,,109.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,12.16,case rate,pays based on per visit rate,345.06,31.95,,137.6,Fee Schedule,31.95% of LA custom fee schedule,2238.94,3890,
Report,4100064,CDM,972,RC,73202,HCPCS,OUTPATIENT,,,183,109.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,62.368,other,Not separately reimbursable,,31.95,,62.368,other,Not separately reimbursable,174.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.08,other,Not separately reimbursable,,,,78.08,other,Not separately reimbursable,2239.94,3891,
CT Upper Extremity w/+w/o Contrast Right,4100064,CDM,350,RC,73202,HCPCS,OUTPATIENT,,,1080,648,26,918,85,,734.4,Percent of total billed charges,85% of total billed charges,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,379.62,35.15,,2.56,fee schedule,35.15% of LA custom fee schedule,345.06,31.95,,2.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.736,case rate,pays based on per visit rate,345.06,31.95,,3.2,Fee Schedule,31.95% of LA custom fee schedule,2240.94,3892,
FMC CT Upper Extremity w/+w/o Contrast Right,4100064,CDM,350,RC,73202,HCPCS,OUTPATIENT,,,1080,648,26,918,85,,734.4,Percent of total billed charges,85% of total billed charges,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,379.62,35.15,,18.4,fee schedule,35.15% of LA custom fee schedule,345.06,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.736,case rate,pays based on per visit rate,345.06,31.95,,23.04,Fee Schedule,31.95% of LA custom fee schedule,2241.94,3893,
Report,4100065,CDM,972,RC,73201,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,278.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.032,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,133.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,103.968,other,Not separately reimbursable,,,,6.392,other,Not separately reimbursable,2242.94,3894,
CT Upper Extremity w/ Contrast Bilateral,4100065,CDM,350,RC,73201,HCPCS,OUTPATIENT,,,1125,675,26,956.25,85,,765,Percent of total billed charges,85% of total billed charges,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,395.44,35.15,,12.016,fee schedule,35.15% of LA custom fee schedule,359.44,31.95,,12.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,3.04,case rate,pays based on per visit rate,359.44,31.95,,15.04,Fee Schedule,31.95% of LA custom fee schedule,2243.94,3895,
CT Upper Extremity w/ Contrast Bilateral Profee,4100065,CDM,972,RC,73201,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,278.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.904,other,Not separately reimbursable,,31.95,,6.904,other,Not separately reimbursable,133.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.464,other,Not separately reimbursable,,,,8.64,other,Not separately reimbursable,2244.94,3896,
Report,4100066,CDM,972,RC,73201,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,278.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.392,other,Not separately reimbursable,,31.95,,6.392,other,Not separately reimbursable,133.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,8,other,Not separately reimbursable,2245.94,3897,
CT Upper Extremity w/ Contrast Left,4100066,CDM,350,RC,73201,HCPCS,OUTPATIENT,,,1125,675,26,956.25,85,,765,Percent of total billed charges,85% of total billed charges,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,395.44,35.15,,12.528,fee schedule,35.15% of LA custom fee schedule,359.44,31.95,,12.528,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,25.992,case rate,pays based on per visit rate,359.44,31.95,,15.68,Fee Schedule,31.95% of LA custom fee schedule,2246.94,3898,
Report,4100067,CDM,972,RC,73201,HCPCS,OUTPATIENT,,,174,104.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,278.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,109.912,other,Not separately reimbursable,,31.95,,109.912,other,Not separately reimbursable,133.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,137.6,other,Not separately reimbursable,2247.94,3899,
CT Upper Extremity w/ Contrast Right,4100067,CDM,350,RC,73201,HCPCS,OUTPATIENT,,,1125,675,26,956.25,85,,765,Percent of total billed charges,85% of total billed charges,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,395.44,35.15,,4.344,fee schedule,35.15% of LA custom fee schedule,359.44,31.95,,4.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,13.68,case rate,pays based on per visit rate,359.44,31.95,,5.44,Fee Schedule,31.95% of LA custom fee schedule,2248.94,3900,
FMC CT Upper Extremity w/ Contrast Right,4100067,CDM,350,RC,73201,HCPCS,OUTPATIENT,,,1125,675,26,956.25,85,,765,Percent of total billed charges,85% of total billed charges,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,682.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,395.44,35.15,,2.304,fee schedule,35.15% of LA custom fee schedule,359.44,31.95,,2.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,15.504,case rate,pays based on per visit rate,359.44,31.95,,2.88,Fee Schedule,31.95% of LA custom fee schedule,2249.94,3901,
Report,4100068,CDM,972,RC,73200,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,63.904,other,Not separately reimbursable,,31.95,,63.904,other,Not separately reimbursable,104.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,79.952,other,Not separately reimbursable,,,,80,other,Not separately reimbursable,2250.94,3902,
CT Upper Extremity w/o contrast bilat Profee,4100068,CDM,972,RC,73200,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,99.176,other,Not separately reimbursable,,31.95,,99.176,other,Not separately reimbursable,104.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,124.16,other,Not separately reimbursable,2251.94,3903,
Report,4100069,CDM,972,RC,73200,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,176.368,other,Not separately reimbursable,,31.95,,176.368,other,Not separately reimbursable,104.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.432,other,Not separately reimbursable,,,,220.8,other,Not separately reimbursable,2252.94,3904,
CT Upper Extremity w/o Contrast Left,4100069,CDM,350,RC,73200,HCPCS,OUTPATIENT,,,950,570,26,807.5,85,,646,Percent of total billed charges,85% of total billed charges,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,333.93,35.15,,1.536,fee schedule,35.15% of LA custom fee schedule,303.53,31.95,,1.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,68.704,case rate,pays based on per visit rate,303.53,31.95,,1.92,Fee Schedule,31.95% of LA custom fee schedule,2253.94,3905,
CT Upper Extremity w/o Contrast Bilat,4100069,CDM,350,RC,73200,HCPCS,OUTPATIENT,,,950,570,26,807.5,85,,646,Percent of total billed charges,85% of total billed charges,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,333.93,35.15,,2.304,fee schedule,35.15% of LA custom fee schedule,303.53,31.95,,2.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,0.488,case rate,pays based on per visit rate,303.53,31.95,,2.88,Fee Schedule,31.95% of LA custom fee schedule,2254.94,3906,
Report,4100070,CDM,972,RC,73200,HCPCS,OUTPATIENT,,,149,89.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.048,other,Not separately reimbursable,,31.95,,2.048,other,Not separately reimbursable,104.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.808,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,2255.94,3907,
CT Upper Extremity w/o Contrast Right,4100070,CDM,350,RC,73200,HCPCS,OUTPATIENT,,,950,570,26,807.5,85,,646,Percent of total billed charges,85% of total billed charges,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,333.93,35.15,,2.304,fee schedule,35.15% of LA custom fee schedule,303.53,31.95,,2.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,2.128,case rate,pays based on per visit rate,303.53,31.95,,2.88,Fee Schedule,31.95% of LA custom fee schedule,2256.94,3908,
FMC CT Upper Extremity w/o Contrast Right,4100070,CDM,350,RC,73200,HCPCS,OUTPATIENT,,,950,570,26,807.5,85,,646,Percent of total billed charges,85% of total billed charges,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,333.93,35.15,,1.792,fee schedule,35.15% of LA custom fee schedule,303.53,31.95,,1.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,20.6,case rate,pays based on per visit rate,303.53,31.95,,2.24,Fee Schedule,31.95% of LA custom fee schedule,2257.94,3909,
CT Angiography Abdomen/Pelvis,4100071,CDM,351,RC,74174,HCPCS,OUTPATIENT,,,1110,666,TC,943.5,85,,754.8,Percent of total billed charges,85% of total billed charges,1315.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1315.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,390.17,35.15,,12.272,fee schedule,35.15% of LA custom fee schedule,354.65,31.95,,12.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.384,case rate,pays based on per visit rate,354.65,31.95,,15.36,Fee Schedule,31.95% of LA custom fee schedule,2258.94,3910,
Report,4100071,CDM,972,RC,74174,HCPCS,OUTPATIENT,,,331,198.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,495.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.088,other,Not separately reimbursable,,31.95,,4.088,other,Not separately reimbursable,253.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.912,other,Not separately reimbursable,,,,5.12,other,Not separately reimbursable,2259.94,3911,
CT Angiography Abdomen/Pelvis Profee,4100071,CDM,972,RC,74174,HCPCS,OUTPATIENT,,,331,198.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,495.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,56.744,other,Not separately reimbursable,,31.95,,56.744,other,Not separately reimbursable,253.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.376,other,Not separately reimbursable,,,,71.04,other,Not separately reimbursable,2260.94,3912,
FMC CT Angiography Abdomen/ Pelvis,4100071,CDM,270,RC,74174,HCPCS,OUTPATIENT,,,331,198.6,TC,281.35,85,,225.08,Percent of total billed charges,85% of total billed charges,1315.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1315.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.35,35.15,,89.712,fee schedule,35.15% of LA custom fee schedule,105.75,31.95,,89.712,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,125.78,38,,9.12,percent of total billed charges,38% of total billed charges,105.75,31.95,,112.32,Fee Schedule,31.95% of LA custom fee schedule,2261.94,3913,
CT Angiography Abdomen/Pelvis,4100071,CDM,351,RC,74174,HCPCS,OUTPATIENT,,,1110,666,TC,943.5,85,,754.8,Percent of total billed charges,85% of total billed charges,1315.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1315.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,390.17,35.15,,88.696,fee schedule,35.15% of LA custom fee schedule,354.65,31.95,,88.696,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,3.344,case rate,pays based on per visit rate,354.65,31.95,,111.04,Fee Schedule,31.95% of LA custom fee schedule,2262.94,3914,
Report,4100072,CDM,972,RC,74175,HCPCS,OUTPATIENT,,,271,162.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,364.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1150.2,other,Not separately reimbursable,,31.95,,1150.2,other,Not separately reimbursable,201.51,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,1440,other,Not separately reimbursable,2263.94,3915,
CT Angiography Abdomen,4100072,CDM,352,RC,74175,HCPCS,OUTPATIENT,,,1355,813,26,1151.75,85,,921.4,Percent of total billed charges,85% of total billed charges,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,1150.2,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,1150.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,9.728,case rate,pays based on per visit rate,432.92,31.95,,1440,Fee Schedule,31.95% of LA custom fee schedule,2264.94,3916,
CT Angiography Aorta w/ Runoff,4100073,CDM,352,RC,75635,HCPCS,OUTPATIENT,,,1100,660,TC,935,85,,748,Percent of total billed charges,85% of total billed charges,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,386.65,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,351.45,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,6.384,case rate,pays based on per visit rate,351.45,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,2265.94,3917,
Report,4100073,CDM,972,RC,75635,HCPCS,OUTPATIENT,,,358,214.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,402.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,,31.95,,1.28,other,Not separately reimbursable,273.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.648,other,Not separately reimbursable,,,,1.6,other,Not separately reimbursable,2266.94,3918,
CT Angio Chest,4100074,CDM,352,RC,71275,HCPCS,OUTPATIENT,,,1355,813,TC,1151.75,85,,921.4,Percent of total billed charges,85% of total billed charges,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,11.248,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,11.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,3.344,case rate,pays based on per visit rate,432.92,31.95,,14.08,Fee Schedule,31.95% of LA custom fee schedule,2267.94,3919,
Report,4100074,CDM,972,RC,71275,HCPCS,OUTPATIENT,,,273,163.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,365.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,0.256,other,Not separately reimbursable,,31.95,,0.256,other,Not separately reimbursable,179.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,0.32,other,Not separately reimbursable,2268.94,3920,
CT Angiography Chest Profee,4100074,CDM,972,RC,71275,HCPCS,OUTPATIENT,,,273,163.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,365.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,0.768,other,Not separately reimbursable,,31.95,,0.768,other,Not separately reimbursable,179.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.248,other,Not separately reimbursable,,,,0.96,other,Not separately reimbursable,2269.94,3921,
CT Angiography Chest,4100074,CDM,352,RC,71275,HCPCS,OUTPATIENT,,,1355,813,TC,1151.75,85,,921.4,Percent of total billed charges,85% of total billed charges,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,2.048,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,2.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,8.512,case rate,pays based on per visit rate,432.92,31.95,,2.56,Fee Schedule,31.95% of LA custom fee schedule,2270.94,3922,
CT Angio Pelvis,4100075,CDM,352,RC,72191,HCPCS,OUTPATIENT,,,1355,813,TC,1151.75,85,,921.4,Percent of total billed charges,85% of total billed charges,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,927.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,79.744,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,79.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,12.16,case rate,pays based on per visit rate,432.92,31.95,,99.84,Fee Schedule,31.95% of LA custom fee schedule,2271.94,3923,
Report,4100075,CDM,972,RC,72191,HCPCS,OUTPATIENT,,,270,162,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,364.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.224,other,Not separately reimbursable,,31.95,,10.224,other,Not separately reimbursable,201.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.432,other,Not separately reimbursable,,,,12.8,other,Not separately reimbursable,2272.94,3924,
FMC EPOGEN 4000 UNIT/1 ML,4100076,CDM,636,RC,J0885,HCPCS,OUTPATIENT,,,175,105,TC,148.75,85,,119,Percent of total billed charges,85% of total billed charges,10.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,9.456,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,9.456,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.83,100,,7.904,case rate,pays based on per visit rate,55.91,31.95,,11.84,Fee Schedule,31.95% of LA custom fee schedule,2273.94,3925,
MA Mammogram Diagnostic Bilateral.,4100077,CDM,401,RC,77066,HCPCS,OUTPATIENT,,,597,358.2,TC,507.45,85,,405.96,Percent of total billed charges,85% of total billed charges,198.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,198.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,209.85,35.15,,2.048,fee schedule,35.15% of LA custom fee schedule,190.74,31.95,,2.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,6.688,case rate,pays based on per visit rate,190.74,31.95,,2.56,Fee Schedule,31.95% of LA custom fee schedule,2274.94,3926,
Report,4100077,CDM,972,RC,77066,HCPCS,OUTPATIENT,,,131,78.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.272,other,Not separately reimbursable,,31.95,,12.272,other,Not separately reimbursable,98.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.344,other,Not separately reimbursable,,,,15.36,other,Not separately reimbursable,2275.94,3927,
MA Mammo Diagnostic 3D Bilateral.,4100077,CDM,401,RC,77066,HCPCS,OUTPATIENT,,,597,358.2,TC,507.45,85,,405.96,Percent of total billed charges,85% of total billed charges,198.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,198.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,209.85,35.15,,2.808,fee schedule,35.15% of LA custom fee schedule,190.74,31.95,,2.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,12.768,case rate,pays based on per visit rate,190.74,31.95,,3.52,Fee Schedule,31.95% of LA custom fee schedule,2276.94,3928,
Report,4100077,CDM,972,RC,77066,HCPCS,OUTPATIENT,,,131,78.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.064,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,98.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.52,other,Not separately reimbursable,,,,3.84,other,Not separately reimbursable,2277.94,3929,
Report,4100078,CDM,972,RC,77065,HCPCS,OUTPATIENT,,,105,63,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,,31.95,,2.56,other,Not separately reimbursable,76.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,2278.94,3930,
MA Mammogram Diagnostic Right.,4100078,CDM,401,RC,77065,HCPCS,OUTPATIENT,,,471,282.6,26,400.35,85,,320.28,Percent of total billed charges,85% of total billed charges,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,165.56,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,150.48,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,10.336,case rate,pays based on per visit rate,150.48,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2279.94,3931,
Report,4100078,CDM,972,RC,77065,HCPCS,OUTPATIENT,,,105,63,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,0.768,other,Not separately reimbursable,,31.95,,0.768,other,Not separately reimbursable,76.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.728,other,Not separately reimbursable,,,,0.96,other,Not separately reimbursable,2280.94,3932,
MA Mammogram Diagnostic Left.,4100078,CDM,401,RC,77065,HCPCS,OUTPATIENT,,,471,282.6,26,400.35,85,,320.28,Percent of total billed charges,85% of total billed charges,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,165.56,35.15,,3.32,fee schedule,35.15% of LA custom fee schedule,150.48,31.95,,3.32,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,19.152,case rate,pays based on per visit rate,150.48,31.95,,4.16,Fee Schedule,31.95% of LA custom fee schedule,2281.94,3933,
MA Mammo Diagnostic 3D Left.,4100078,CDM,401,RC,77065,HCPCS,OUTPATIENT,,,471,282.6,26,400.35,85,,320.28,Percent of total billed charges,85% of total billed charges,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,165.56,35.15,,10.992,fee schedule,35.15% of LA custom fee schedule,150.48,31.95,,10.992,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,19.152,case rate,pays based on per visit rate,150.48,31.95,,13.76,Fee Schedule,31.95% of LA custom fee schedule,2282.94,3934,
Report,4100078,CDM,972,RC,77065,HCPCS,OUTPATIENT,,,105,63,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.272,other,Not separately reimbursable,,31.95,,12.272,other,Not separately reimbursable,76.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,15.36,other,Not separately reimbursable,2283.94,3935,
MA Mammo Diagnostic 3D Right.,4100078,CDM,401,RC,77065,HCPCS,OUTPATIENT,,,471,282.6,26,400.35,85,,320.28,Percent of total billed charges,85% of total billed charges,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,165.56,35.15,,13.544,fee schedule,35.15% of LA custom fee schedule,150.48,31.95,,13.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,18.848,case rate,pays based on per visit rate,150.48,31.95,,16.96,Fee Schedule,31.95% of LA custom fee schedule,2284.94,3936,
Report,4100078,CDM,972,RC,77065,HCPCS,OUTPATIENT,,,105,63,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,14.568,other,Not separately reimbursable,,31.95,,14.568,other,Not separately reimbursable,76.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.424,other,Not separately reimbursable,,,,18.24,other,Not separately reimbursable,2285.94,3937,
MA Breast Ndl Loc Placement Lt,4100079,CDM,401,RC,19281,HCPCS,OUTPATIENT,,,1500,900,TC,1275,85,,1020,Percent of total billed charges,85% of total billed charges,413.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,413.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,15.592,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,15.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,300,100,,10.336,case rate,pays based on per visit rate,600,40,,19.52,percent of total billed charges,40% of total billed charges,2286.94,3938,
Report,4100079,CDM,972,RC,19281,HCPCS,OUTPATIENT,,,310,186,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,258.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,17.128,other,Not separately reimbursable,,31.95,,17.128,other,Not separately reimbursable,92.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.416,other,Not separately reimbursable,,,,21.44,other,Not separately reimbursable,2287.94,3939,
MA Breast Ndl Loc Placement Rt,4100079,CDM,401,RC,19281,HCPCS,OUTPATIENT,,,1500,900,TC,1275,85,,1020,Percent of total billed charges,85% of total billed charges,413.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,413.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,300,100,,1.216,case rate,pays based on per visit rate,600,40,,7.68,percent of total billed charges,40% of total billed charges,2288.94,3940,
Report,4100079,CDM,972,RC,19281,HCPCS,OUTPATIENT,,,310,186,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,258.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.176,other,Not separately reimbursable,,31.95,,8.176,other,Not separately reimbursable,92.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.984,other,Not separately reimbursable,,,,10.24,other,Not separately reimbursable,2289.94,3941,
MA Breast Ndl Loc Placement Lt Addl,4100080,CDM,401,RC,19282,HCPCS,OUTPATIENT,,,214,128.4,TC,181.9,85,,145.52,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.37,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,68.37,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,300,100,,13.376,case rate,pays based on per visit rate,85.6,40,,5.12,percent of total billed charges,40% of total billed charges,2290.94,3942,
Report,4100080,CDM,972,RC,19282,HCPCS,OUTPATIENT,,,107,64.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.392,other,Not separately reimbursable,,31.95,,6.392,other,Not separately reimbursable,46.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.296,other,Not separately reimbursable,,,,8,other,Not separately reimbursable,2291.94,3943,
MA Breast Ndl Loc Placement Rt Addl,4100080,CDM,401,RC,19282,HCPCS,OUTPATIENT,,,214,128.4,TC,181.9,85,,145.52,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.37,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,68.37,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,300,100,,26.448,case rate,pays based on per visit rate,85.6,40,,16,percent of total billed charges,40% of total billed charges,2292.94,3944,
Report,4100080,CDM,972,RC,19282,HCPCS,OUTPATIENT,,,107,64.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.032,other,Not separately reimbursable,,31.95,,13.032,other,Not separately reimbursable,46.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,16.32,other,Not separately reimbursable,2293.94,3945,
MA Mammogram Routine Screening Bilat.,4100081,CDM,403,RC,77067,HCPCS,OUTPATIENT,,,540,324,TC,459,85,,367.2,Percent of total billed charges,85% of total billed charges,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.81,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,172.53,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,8.816,case rate,pays based on per visit rate,172.53,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,2294.94,3946,
Report,4100081,CDM,972,RC,77067,HCPCS,OUTPATIENT,,,148,88.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,,31.95,,1.28,other,Not separately reimbursable,81.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.64,other,Not separately reimbursable,,,,1.6,other,Not separately reimbursable,2295.94,3947,
MA Mammo Screening 3D Bilateral,4100081,CDM,403,RC,77067,HCPCS,OUTPATIENT,,,540,324,TC,459,85,,367.2,Percent of total billed charges,85% of total billed charges,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.81,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,172.53,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,9.424,case rate,pays based on per visit rate,172.53,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,2296.94,3948,
Report,4100081,CDM,972,RC,77067,HCPCS,OUTPATIENT,,,105,63,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,,31.95,,1.28,other,Not separately reimbursable,81.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.816,other,Not separately reimbursable,,,,1.6,other,Not separately reimbursable,2297.94,3949,
MA Mammogram Routine Screening Left.,4100082,CDM,403,RC,77067,HCPCS,OUTPATIENT,,,540,324,1-52|2-TC|3-LT,459,85,,367.2,Percent of total billed charges,85% of total billed charges,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.81,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,172.53,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,4.56,case rate,pays based on per visit rate,172.53,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,2298.94,3950,
Report,4100082,CDM,972,RC,77067,HCPCS,OUTPATIENT,,,105,63,1-52|2-TC|3-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.064,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,81.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,3.84,other,Not separately reimbursable,2299.94,3951,
"FMC MR CONTRAST,MR INJ GRAD-B",4100082,CDM,636,RC,A9579,HCPCS,OUTPATIENT,,,6,3.6,1-52|2-TC|3-LT,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,2.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2.11,35.15,,0.504,percent of total billed charges,35.15% of total billed charges,10.64,31.95,,0.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,58.368,other,Not separately reimbursable,1.92,31.95,,0.632,percent of total billed charges,31.95% of total billed charges,2300.94,3952,
MA Mammo Screening 3D Left,4100082,CDM,403,RC,77067,HCPCS,OUTPATIENT,,,540,324,1-52|2-TC|3-LT,459,85,,367.2,Percent of total billed charges,85% of total billed charges,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.81,35.15,,0.512,fee schedule,35.15% of LA custom fee schedule,172.53,31.95,,0.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,0.912,case rate,pays based on per visit rate,172.53,31.95,,0.64,Fee Schedule,31.95% of LA custom fee schedule,2301.94,3953,
Report,4100082,CDM,972,RC,77067,HCPCS,OUTPATIENT,,,105,63,1-52|2-TC|3-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,81.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2302.94,3954,
MRA Abdomen w/ + w/o Contrast,4100083,CDM,618,RC,C8902,HCPCS,OUTPATIENT,,,1800,1080,TC,1530,85,,1224,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,575.1,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,575.1,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,61.408,case rate,pays based on per visit rate,720,40,,4,percent of total billed charges,40% of total billed charges,2303.94,3955,
MRA Abdomen w/ Contrast,4100084,CDM,618,RC,C8900,HCPCS,OUTPATIENT,,,1748,1048.8,TC,1485.8,85,,1188.64,Percent of total billed charges,85% of total billed charges,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,558.49,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,558.49,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,23.712,case rate,pays based on per visit rate,699.2,40,,4,percent of total billed charges,40% of total billed charges,2304.94,3956,
MRA Abdomen w/o Contrast,4100085,CDM,618,RC,C8901,HCPCS,OUTPATIENT,,,1600,960,TC,1360,85,,1088,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,511.2,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,511.2,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,16.416,case rate,pays based on per visit rate,640,40,,144,percent of total billed charges,40% of total billed charges,2305.94,3957,
MRA Chest w/ + w/o Contrast,4100086,CDM,618,RC,C8911,HCPCS,OUTPATIENT,,,1700,1020,TC,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,543.15,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,543.15,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,48.336,case rate,pays based on per visit rate,680,40,,27.2,percent of total billed charges,40% of total billed charges,2306.94,3958,
MRA Chest w/ Contrast,4100087,CDM,618,RC,C8909,HCPCS,OUTPATIENT,,,1500,900,TC,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,3.952,case rate,pays based on per visit rate,600,40,,2.24,percent of total billed charges,40% of total billed charges,2307.94,3959,
MRA Chest w/o Contrast,4100088,CDM,618,RC,C8910,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,1.824,case rate,pays based on per visit rate,560,40,,2.56,percent of total billed charges,40% of total billed charges,2308.94,3960,
Report,4100089,CDM,972,RC,70546,HCPCS,OUTPATIENT,,,270,162,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,506.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,237.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2309.94,3961,
MRA Head w/ + w/o Contrast,4100089,CDM,615,RC,70546,HCPCS,OUTPATIENT,,,1800,1080,26,1530,85,,1224,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,575.1,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,575.1,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,13.072,case rate,pays based on per visit rate,720,40,,3.2,percent of total billed charges,40% of total billed charges,2310.94,3962,
Report,4100090,CDM,972,RC,70545,HCPCS,OUTPATIENT,,,179,107.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,343.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.024,other,Not separately reimbursable,,31.95,,1.024,other,Not separately reimbursable,156.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,19.456,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,2311.94,3963,
MRA Head w/ Contrast,4100090,CDM,615,RC,70545,HCPCS,OUTPATIENT,,,1600,960,26,1360,85,,1088,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,511.2,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,511.2,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,13.984,case rate,pays based on per visit rate,640,40,,5.76,percent of total billed charges,40% of total billed charges,2312.94,3964,
Report,4100091,CDM,972,RC,70544,HCPCS,OUTPATIENT,,,180,108,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,346.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,207.8,other,Not separately reimbursable,,31.95,,207.8,other,Not separately reimbursable,145.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.984,other,Not separately reimbursable,,,,260.16,other,Not separately reimbursable,2313.94,3965,
MRA Head w/o Contrast,4100091,CDM,615,RC,70544,HCPCS,OUTPATIENT,,,1400,840,26,1190,85,,952,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,13.072,case rate,pays based on per visit rate,560,40,,16,percent of total billed charges,40% of total billed charges,2314.94,3966,
MRA Lower Ext w/ + w/o Contrast,4100092,CDM,616,RC,C8914,HCPCS,OUTPATIENT,,,1400,840,1-TC|2-TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,75.696,case rate,pays based on per visit rate,560,40,,25.6,percent of total billed charges,40% of total billed charges,2315.94,3967,
MRA Femur w/ + w/o Contrast Left,4100093,CDM,616,RC,C8914,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,52.288,case rate,pays based on per visit rate,560,40,,2.24,percent of total billed charges,40% of total billed charges,2316.94,3968,
MRA Foot w/ + w/o Contrast Left,4100093,CDM,616,RC,C8914,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,258.16,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,258.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,4.56,case rate,pays based on per visit rate,560,40,,323.2,percent of total billed charges,40% of total billed charges,2317.94,3969,
MRA Tibia/Fibula w/ + w/o Contrast Left,4100093,CDM,616,RC,C8914,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,2.128,case rate,pays based on per visit rate,560,40,,6.72,percent of total billed charges,40% of total billed charges,2318.94,3970,
MRA Femur w/ + w/o Contrast Right,4100094,CDM,616,RC,C8914,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,12.16,case rate,pays based on per visit rate,560,40,,9.6,percent of total billed charges,40% of total billed charges,2319.94,3971,
MRA Foot w/ + w/o Contrast Right,4100094,CDM,616,RC,C8914,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,484.36,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,484.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,20.368,case rate,pays based on per visit rate,560,40,,606.4,percent of total billed charges,40% of total billed charges,2320.94,3972,
MRA Tibia/Fibula w/ + w/o Contrast Right,4100094,CDM,616,RC,C8914,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,0.896,case rate,pays based on per visit rate,560,40,,12.48,percent of total billed charges,40% of total billed charges,2321.94,3973,
MRA Lower Ext w/ Contrast,4100095,CDM,616,RC,C8912,HCPCS,OUTPATIENT,,,1748,1048.8,1-TC|2-TC,1485.8,85,,1188.64,Percent of total billed charges,85% of total billed charges,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,558.49,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,558.49,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,6.16,case rate,pays based on per visit rate,699.2,40,,110.4,percent of total billed charges,40% of total billed charges,2322.94,3974,
MRA Lower Ext w/o Contrast,4100098,CDM,616,RC,C8913,HCPCS,OUTPATIENT,,,1372,823.2,1-TC|2-TC,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,438.35,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,438.35,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,23.104,case rate,pays based on per visit rate,548.8,40,,83.2,percent of total billed charges,40% of total billed charges,2323.94,3975,
MRA Femur w/o Contrast Left,4100099,CDM,616,RC,C8913,HCPCS,OUTPATIENT,,,1372,823.2,1-TC|2-TC,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,438.35,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,438.35,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,9.728,case rate,pays based on per visit rate,548.8,40,,2.88,percent of total billed charges,40% of total billed charges,2324.94,3976,
MRA Foot w/o Contrast Left,4100099,CDM,616,RC,C8913,HCPCS,OUTPATIENT,,,1372,823.2,1-TC|2-TC,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,438.35,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,438.35,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,31.312,case rate,pays based on per visit rate,548.8,40,,4.8,percent of total billed charges,40% of total billed charges,2325.94,3977,
MRA Tibia/Fibula w/o Contrast Left,4100099,CDM,616,RC,C8913,HCPCS,OUTPATIENT,,,1372,823.2,1-TC|2-TC,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,438.35,31.95,,260.712,percent of total billed charges,31.95% of total billed charges,438.35,31.95,,260.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,74.784,case rate,pays based on per visit rate,548.8,40,,326.4,percent of total billed charges,40% of total billed charges,2326.94,3978,
MRA Femur w/o Contrast Right,4100100,CDM,616,RC,C8913,HCPCS,OUTPATIENT,,,1372,823.2,1-TC|2-TC,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,438.35,31.95,,55.464,percent of total billed charges,31.95% of total billed charges,438.35,31.95,,55.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,42.864,case rate,pays based on per visit rate,548.8,40,,69.44,percent of total billed charges,40% of total billed charges,2327.94,3979,
MRA Foot w/o Contrast Right,4100100,CDM,616,RC,C8913,HCPCS,OUTPATIENT,,,1372,823.2,1-TC|2-TC,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,438.35,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,438.35,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,143.776,case rate,pays based on per visit rate,548.8,40,,350.72,percent of total billed charges,40% of total billed charges,2328.94,3980,
MRA Tibia/Fibula w/o Contrast Right,4100100,CDM,616,RC,C8913,HCPCS,OUTPATIENT,,,1372,823.2,1-TC|2-TC,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,438.35,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,438.35,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,159.784,case rate,pays based on per visit rate,548.8,40,,350.72,percent of total billed charges,40% of total billed charges,2329.94,3981,
Report,4100101,CDM,972,RC,70548,HCPCS,OUTPATIENT,,,180,108,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,383.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,0.944,other,Not separately reimbursable,,31.95,,0.944,other,Not separately reimbursable,160.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,30.4,other,Not separately reimbursable,,,,1.184,other,Not separately reimbursable,2330.94,3982,
MRA Neck w/ Contrast,4100101,CDM,615,RC,70548,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,543.15,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,543.15,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,4.56,case rate,pays based on per visit rate,680,40,,1.392,percent of total billed charges,40% of total billed charges,2331.94,3983,
Report,4100102,CDM,972,RC,70547,HCPCS,OUTPATIENT,,,178,106.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,347.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.344,other,Not separately reimbursable,,31.95,,4.344,other,Not separately reimbursable,146.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,32.528,other,Not separately reimbursable,,,,5.44,other,Not separately reimbursable,2332.94,3984,
MRA Neck w/o Contrast,4100102,CDM,615,RC,70547,HCPCS,OUTPATIENT,,,1400,840,26,1190,85,,952,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,2.432,case rate,pays based on per visit rate,560,40,,2.56,percent of total billed charges,40% of total billed charges,2333.94,3985,
MRA Pelvis w/ + w/o Contrast,4100103,CDM,618,RC,C8920,HCPCS,OUTPATIENT,,,1700,1020,TC,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,543.15,31.95,,2.616,percent of total billed charges,31.95% of total billed charges,543.15,31.95,,2.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,3.648,case rate,pays based on per visit rate,680,40,,3.28,percent of total billed charges,40% of total billed charges,2334.94,3986,
MRA Pelvis w/ Contrast,4100104,CDM,618,RC,C8918,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,560,40,,17.92,percent of total billed charges,40% of total billed charges,2335.94,3987,
MRA Pelvis w/o Contrast,4100105,CDM,618,RC,C8919,HCPCS,OUTPATIENT,,,1100,660,TC,935,85,,748,Percent of total billed charges,85% of total billed charges,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1182.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,351.45,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,351.45,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,2.128,case rate,pays based on per visit rate,440,40,,2.56,percent of total billed charges,40% of total billed charges,2336.94,3988,
Report,4100106,CDM,972,RC,72125,HCPCS,OUTPATIENT,,,160,96,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.816,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,76.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,114.248,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,2337.94,3989,
MRA Spinal Canal,4100106,CDM,350,RC,72125,HCPCS,OUTPATIENT,,,925,555,26,786.25,85,,629,Percent of total billed charges,85% of total billed charges,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,325.14,35.15,,2.816,fee schedule,35.15% of LA custom fee schedule,295.54,31.95,,12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,1.216,case rate,pays based on per visit rate,295.54,31.95,,2.56,Fee Schedule,31.95% of LA custom fee schedule,2338.94,3990,
MRA Spine w/ + w/o Contrast,4100107,CDM,618,RC,72159,HCPCS,OUTPATIENT,,,1500,900,TC,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1412.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1412.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,19.296,case rate,pays based on per visit rate,600,40,,2.56,percent of total billed charges,40% of total billed charges,2339.94,3991,
Report,4100107,CDM,972,RC,72159,HCPCS,OUTPATIENT,,,274,164.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,504.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.816,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,2340.94,3992,
MRA LE w/ Contrast Left,4100108,CDM,323,RC,75710,HCPCS,OUTPATIENT,,,10306,6183.6,1-TC|2-LT,8760.1,85,,7008.08,Percent of total billed charges,85% of total billed charges,2776.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2776.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3292.77,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,3292.77,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,155,100,,66.272,case rate,pays based on per visit rate,4122.4,40,,2.56,percent of total billed charges,40% of total billed charges,2341.94,3993,
Report,4100108,CDM,972,RC,75710,HCPCS,OUTPATIENT,,,285,171,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,217.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.816,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,60.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,35.264,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,2342.94,3994,
MRA LE w/ Contrast Right,4100109,CDM,616,RC,75710,HCPCS,OUTPATIENT,,,10306,6183.6,1-TC|2-RT,8760.1,85,,7008.08,Percent of total billed charges,85% of total billed charges,2776.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2776.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3292.77,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,3292.77,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,2.432,case rate,pays based on per visit rate,4122.4,40,,2.56,percent of total billed charges,40% of total billed charges,2343.94,3995,
Report,4100109,CDM,972,RC,75710,HCPCS,OUTPATIENT,,,285,171,1-TC|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,217.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.304,other,Not separately reimbursable,,31.95,,25.304,other,Not separately reimbursable,60.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,54.72,other,Not separately reimbursable,,,,31.68,other,Not separately reimbursable,2344.94,3996,
Report,4100111,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,279.512,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.368,other,Not separately reimbursable,,,,254.064,other,Not separately reimbursable,2345.94,3997,
MRA Upper Extremity Left,4100111,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,106.328,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,106.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,23.104,case rate,pays based on per visit rate,600,40,,133.12,percent of total billed charges,40% of total billed charges,2346.94,3998,
MRA Forearm w/ + w/o Contrast Left,4100111,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,10.992,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,10.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,33.44,case rate,pays based on per visit rate,600,40,,13.76,percent of total billed charges,40% of total billed charges,2347.94,3999,
Report,4100111,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,27.36,other,Not separately reimbursable,,,,23.04,other,Not separately reimbursable,2348.94,4000,
MRA Hand w/ + w/o Contrast Left,4100111,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,67.48,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,67.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,42.56,case rate,pays based on per visit rate,600,40,,84.48,percent of total billed charges,40% of total billed charges,2349.94,4001,
Report,4100111,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,117.576,other,Not separately reimbursable,,31.95,,117.576,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,32.528,other,Not separately reimbursable,,,,147.2,other,Not separately reimbursable,2350.94,4002,
MRA Humerus w/ + w/o Contrast Left,4100111,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,14.288,case rate,pays based on per visit rate,600,40,,112,percent of total billed charges,40% of total billed charges,2351.94,4003,
Report,4100111,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,117.32,other,Not separately reimbursable,,31.95,,117.32,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,146.88,other,Not separately reimbursable,2352.94,4004,
Report,4100112,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,26.584,other,Not separately reimbursable,,31.95,,26.584,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,51.072,other,Not separately reimbursable,,,,33.28,other,Not separately reimbursable,2353.94,4005,
MRA Upper Extremity Right,4100112,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,5.168,case rate,pays based on per visit rate,600,40,,37.44,percent of total billed charges,40% of total billed charges,2354.94,4006,
MRA Forearm w/ + w/o Contrast Right,4100112,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,35.016,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,35.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,37.696,case rate,pays based on per visit rate,600,40,,43.84,percent of total billed charges,40% of total billed charges,2355.94,4007,
Report,4100112,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,79.296,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,72.08,other,Not separately reimbursable,2356.94,4008,
MRA Hand w/ + w/o Contrast Right,4100112,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,79.296,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,3.04,case rate,pays based on per visit rate,600,40,,72.08,percent of total billed charges,40% of total billed charges,2357.94,4009,
Report,4100112,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,82.112,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,109.44,other,Not separately reimbursable,,,,74.632,other,Not separately reimbursable,2358.94,4010,
MRA Humerus w/ + w/o Contrast Right,4100112,CDM,618,RC,73225,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,109.384,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,21.584,case rate,pays based on per visit rate,600,40,,99.432,percent of total billed charges,40% of total billed charges,2359.94,4011,
Report,4100112,CDM,972,RC,73225,HCPCS,OUTPATIENT,,,256,153.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,79.296,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,238.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,72.08,other,Not separately reimbursable,2360.94,4012,
MRI Abdomen MRCP w/o Cont,4100113,CDM,619,RC,74181,HCPCS,OUTPATIENT,,,1700,1020,TC,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,109.384,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.736,case rate,pays based on per visit rate,543.15,31.95,,99.432,Fee Schedule,31.95% of LA custom fee schedule,2361.94,4013,
Report,4100113,CDM,972,RC,74181,HCPCS,OUTPATIENT,,,218,130.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,306.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,81.552,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,117.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,486.4,other,Not separately reimbursable,,,,74.128,other,Not separately reimbursable,2362.94,4014,
Report,4100114,CDM,972,RC,72149,HCPCS,OUTPATIENT,,,268,160.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,396.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.656,other,Not separately reimbursable,,31.95,,12,other,Not separately reimbursable,171.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.984,other,Not separately reimbursable,,,,11.504,other,Not separately reimbursable,2363.94,4015,
MRI Spine Lumbar w/ Contrast,4100114,CDM,610,RC,72149,HCPCS,OUTPATIENT,,,1900,1140,26,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,18.28,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,50.768,case rate,pays based on per visit rate,607.05,31.95,,16.616,Fee Schedule,31.95% of LA custom fee schedule,2364.94,4016,
Report,4100115,CDM,972,RC,74182,HCPCS,OUTPATIENT,,,260,156,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,447.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.28,other,Not separately reimbursable,,31.95,,117.576,other,Not separately reimbursable,202.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,463.6,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,2365.94,4017,
MRI Abdomen w/ Contrast,4100115,CDM,610,RC,74182,HCPCS,OUTPATIENT,,,1748,1048.8,26,1485.8,85,,1188.64,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,614.42,35.15,,18.28,fee schedule,35.15% of LA custom fee schedule,558.49,31.95,,117.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.736,case rate,pays based on per visit rate,558.49,31.95,,16.616,Fee Schedule,31.95% of LA custom fee schedule,2366.94,4018,
Report,4100116,CDM,972,RC,74183,HCPCS,OUTPATIENT,,,341,204.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,499.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,742.008,other,Not separately reimbursable,,31.95,,742.008,other,Not separately reimbursable,215.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,928.96,other,Not separately reimbursable,2367.94,4019,
MRI Abdomen w/ + w/o Contrast,4100116,CDM,610,RC,74183,HCPCS,OUTPATIENT,,,1850,1110,26,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,835.816,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,835.816,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,9.12,case rate,pays based on per visit rate,591.08,31.95,,1046.4,Fee Schedule,31.95% of LA custom fee schedule,2368.94,4020,
MRI Abdomen w/ + w/o Contrast,4100116,CDM,610,RC,74183,HCPCS,OUTPATIENT,,,1850,1110,26,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,126.264,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,126.264,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,105.184,case rate,pays based on per visit rate,591.08,31.95,,158.08,Fee Schedule,31.95% of LA custom fee schedule,2369.94,4021,
Report,4100117,CDM,972,RC,77084,HCPCS,OUTPATIENT,,,243,145.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,385.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,2.56,other,Not separately reimbursable,,31.95,,2.56,other,Not separately reimbursable,220.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.984,other,Not separately reimbursable,,,,3.2,other,Not separately reimbursable,2370.94,4022,
MRI Bone Marrow Blood,4100117,CDM,610,RC,77084,HCPCS,OUTPATIENT,,,1000,600,26,850,85,,680,Percent of total billed charges,85% of total billed charges,946.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,946.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,351.5,35.15,,137.512,fee schedule,35.15% of LA custom fee schedule,319.5,31.95,,137.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,63.84,case rate,pays based on per visit rate,319.5,31.95,,172.16,Fee Schedule,31.95% of LA custom fee schedule,2371.94,4023,
Report,4100118,CDM,972,RC,70553,HCPCS,OUTPATIENT,,,343,205.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,465.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1483.76,other,Not separately reimbursable,,31.95,,1483.76,other,Not separately reimbursable,193.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.168,other,Not separately reimbursable,,,,1857.6,other,Not separately reimbursable,2372.94,4024,
MRI Brain w/ + w/o Contrast,4100118,CDM,610,RC,70553,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,11.552,case rate,pays based on per visit rate,682.13,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2373.94,4025,
FMC MRI Brain w/ + w/o Cont Profee,4100118,CDM,972,RC,70553,HCPCS,OUTPATIENT,,,343,205.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,465.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,109.384,other,Not separately reimbursable,,31.95,,117.576,other,Not separately reimbursable,193.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,39.824,other,Not separately reimbursable,,,,99.432,other,Not separately reimbursable,2374.94,4026,
FMC MRI Brain w/ + w/o Cont,4100118,CDM,610,RC,70553,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,81.552,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,117.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,80.256,case rate,pays based on per visit rate,682.13,31.95,,74.128,Fee Schedule,31.95% of LA custom fee schedule,2375.94,4027,
Report,4100119,CDM,972,RC,70552,HCPCS,OUTPATIENT,,,268,160.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,393.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,99.432,other,Not separately reimbursable,,31.95,,99.432,other,Not separately reimbursable,171.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.672,other,Not separately reimbursable,,,,124.48,other,Not separately reimbursable,2376.94,4028,
MRI Brain w/ Contrast,4100119,CDM,610,RC,70552,HCPCS,OUTPATIENT,,,1748,1048.8,26,1485.8,85,,1188.64,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,614.42,35.15,,843.48,fee schedule,35.15% of LA custom fee schedule,558.49,31.95,,843.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,84.512,case rate,pays based on per visit rate,558.49,31.95,,1056,Fee Schedule,31.95% of LA custom fee schedule,2377.94,4029,
Report,4100120,CDM,972,RC,70551,HCPCS,OUTPATIENT,,,221,132.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,284.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,107.352,other,Not separately reimbursable,,31.95,,107.352,other,Not separately reimbursable,116.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.384,other,Not separately reimbursable,,,,134.4,other,Not separately reimbursable,2378.94,4030,
MRI Brain w/o Contrast,4100120,CDM,610,RC,70551,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,527.25,35.15,,107.352,fee schedule,35.15% of LA custom fee schedule,479.25,31.95,,107.352,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.128,case rate,pays based on per visit rate,479.25,31.95,,134.4,Fee Schedule,31.95% of LA custom fee schedule,2379.94,4031,
MRI Breast w/ + w/o Contrast Bilateral,4100121,CDM,614,RC,C8908,HCPCS,OUTPATIENT,,,1800,1080,1-50|2-TC,1530,85,,1224,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,575.1,31.95,,762.968,percent of total billed charges,31.95% of total billed charges,575.1,31.95,,762.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,2.432,case rate,pays based on per visit rate,720,40,,955.2,percent of total billed charges,40% of total billed charges,2380.94,4032,
MRI Breast w/ Contrast Bilateral,4100122,CDM,614,RC,C8906,HCPCS,OUTPATIENT,,,1700,1020,1-50|2-TC,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,543.15,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,543.15,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,17.632,case rate,pays based on per visit rate,680,40,,24,percent of total billed charges,40% of total billed charges,2381.94,4033,
MRI Breast w/o Contrast Bilateral,4100123,CDM,614,RC,77047,HCPCS,OUTPATIENT,,,580,348,1-50|2-TC,493,85,,394.4,Percent of total billed charges,85% of total billed charges,534.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,534.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,185.31,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,185.31,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,15.808,case rate,pays based on per visit rate,232,40,,21.12,percent of total billed charges,40% of total billed charges,2382.94,4034,
MRI Breast w/ + w/o Contrast Left,4100124,CDM,614,RC,C8905,HCPCS,OUTPATIENT,,,1500,900,1-LT|2-TC,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,2.768,case rate,pays based on per visit rate,600,40,,62.4,percent of total billed charges,40% of total billed charges,2383.94,4035,
MRI Breast w/ + w/o Contrast Right,4100125,CDM,614,RC,C8905,HCPCS,OUTPATIENT,,,1500,900,1-RT|2-TC,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1714.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,479.25,31.95,,137.512,percent of total billed charges,31.95% of total billed charges,479.25,31.95,,137.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,3.648,case rate,pays based on per visit rate,600,40,,172.16,percent of total billed charges,40% of total billed charges,2384.94,4036,
MRI Breast w/ Contrast Left,4100126,CDM,614,RC,C8903,HCPCS,OUTPATIENT,,,1200,720,1-LT|2-TC,1020,85,,816,Percent of total billed charges,85% of total billed charges,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,383.4,31.95,,160.776,percent of total billed charges,31.95% of total billed charges,383.4,31.95,,160.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,3.648,case rate,pays based on per visit rate,480,40,,201.28,percent of total billed charges,40% of total billed charges,2385.94,4037,
MRI Breast w/ Contrast Right,4100127,CDM,614,RC,C8903,HCPCS,OUTPATIENT,,,1200,720,1-RT|2-TC,1020,85,,816,Percent of total billed charges,85% of total billed charges,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1256.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,383.4,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,383.4,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,13.376,case rate,pays based on per visit rate,480,40,,83.2,percent of total billed charges,40% of total billed charges,2386.94,4038,
MRI Breast w/o Contrast Unilateral,4100128,CDM,614,RC,77046,HCPCS,OUTPATIENT,,,580,348,TC,493,85,,394.4,Percent of total billed charges,85% of total billed charges,534.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,534.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,185.31,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,185.31,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,13.072,case rate,pays based on per visit rate,232,40,,83.2,percent of total billed charges,40% of total billed charges,2387.94,4039,
Report,4100131,CDM,972,RC,75557,HCPCS,OUTPATIENT,,,348,208.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,410.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,305.952,other,Not separately reimbursable,,31.95,,305.952,other,Not separately reimbursable,156.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,383.04,other,Not separately reimbursable,2388.94,4040,
MRI Cardiac Morphology w/o Contrast,4100131,CDM,610,RC,75557,HCPCS,OUTPATIENT,,,1300,780,26,1105,85,,884,Percent of total billed charges,85% of total billed charges,796.02,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.02,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,456.95,35.15,,66.456,fee schedule,35.15% of LA custom fee schedule,415.35,31.95,,66.456,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,11.552,case rate,pays based on per visit rate,415.35,31.95,,83.2,Fee Schedule,31.95% of LA custom fee schedule,2389.94,4041,
Report,4100133,CDM,972,RC,75565,HCPCS,OUTPATIENT,,,37,22.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,66.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,49.328,other,Not separately reimbursable,,31.95,,49.328,other,Not separately reimbursable,30.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.96,other,Not separately reimbursable,,,,61.76,other,Not separately reimbursable,2390.94,4042,
MRI Cardiac Function Limited,4100133,CDM,610,RC,75565,HCPCS,OUTPATIENT,,,1150,690,26,977.5,85,,782,Percent of total billed charges,85% of total billed charges,228.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,404.23,35.15,,44.216,fee schedule,35.15% of LA custom fee schedule,367.43,31.95,,44.216,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,31.616,case rate,pays based on per visit rate,367.43,31.95,,55.36,Fee Schedule,31.95% of LA custom fee schedule,2391.94,4043,
Report,4100134,CDM,972,RC,72156,HCPCS,OUTPATIENT,,,343,205.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,468.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,51.12,other,Not separately reimbursable,,31.95,,51.12,other,Not separately reimbursable,195.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,64,other,Not separately reimbursable,2392.94,4044,
MRI Spine Cervical w/ + w/o Contrast,4100134,CDM,610,RC,72156,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,1610.28,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,1610.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,307.04,case rate,pays based on per visit rate,682.13,31.95,,2016,Fee Schedule,31.95% of LA custom fee schedule,2393.94,4045,
Report,4100135,CDM,972,RC,72141,HCPCS,OUTPATIENT,,,221,132.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,278.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.024,other,Not separately reimbursable,,31.95,,1.024,other,Not separately reimbursable,111.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,2394.94,4046,
MRI Spine Cervical w/o Contrast,4100135,CDM,610,RC,72141,HCPCS,OUTPATIENT,,,1550,930,26,1317.5,85,,1054,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,544.83,35.15,,1.28,fee schedule,35.15% of LA custom fee schedule,495.23,31.95,,1.28,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,3.8,case rate,pays based on per visit rate,495.23,31.95,,1.6,Fee Schedule,31.95% of LA custom fee schedule,2395.94,4047,
Report,4100136,CDM,972,RC,71552,HCPCS,OUTPATIENT,,,341,204.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,615.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.656,other,Not separately reimbursable,,31.95,,18.656,other,Not separately reimbursable,333.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.992,other,Not separately reimbursable,,,,23.36,other,Not separately reimbursable,2396.94,4048,
MRI Chest w/ + w/o Contrast,4100136,CDM,610,RC,71552,HCPCS,OUTPATIENT,,,2100,1260,26,1785,85,,1428,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,738.15,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,670.95,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,3.8,case rate,pays based on per visit rate,670.95,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,2397.94,4049,
Report,4100137,CDM,972,RC,71551,HCPCS,OUTPATIENT,,,260,156,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,556.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1456.92,other,Not separately reimbursable,,31.95,,1456.92,other,Not separately reimbursable,260,100,,,fee schedule,100% of CMS physician fee schedule,,,,57.456,other,Not separately reimbursable,,,,1824,other,Not separately reimbursable,2398.94,4050,
MRI Chest w/ Contrast,4100137,CDM,610,RC,71551,HCPCS,OUTPATIENT,,,1900,1140,26,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,7.416,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,7.416,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,25.84,case rate,pays based on per visit rate,607.05,31.95,,9.28,Fee Schedule,31.95% of LA custom fee schedule,2399.94,4051,
Report,4100138,CDM,972,RC,71550,HCPCS,OUTPATIENT,,,218,130.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,374.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,322.312,other,Not separately reimbursable,,31.95,,322.312,other,Not separately reimbursable,218,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,403.52,other,Not separately reimbursable,2400.94,4052,
MRI Chest w/o Contrast,4100138,CDM,610,RC,71550,HCPCS,OUTPATIENT,,,1372,823.2,26,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,191.704,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,191.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,272.08,case rate,pays based on per visit rate,438.35,31.95,,240,Fee Schedule,31.95% of LA custom fee schedule,2401.94,4053,
Report,4100139,CDM,972,RC,72142,HCPCS,OUTPATIENT,,,268,160.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,401.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,164.864,other,Not separately reimbursable,,31.95,,164.864,other,Not separately reimbursable,175.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,108.224,other,Not separately reimbursable,,,,206.4,other,Not separately reimbursable,2402.94,4054,
MRI Spine Cervical w/ Contrast,4100139,CDM,610,RC,72142,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,220.072,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,220.072,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,108.224,case rate,pays based on per visit rate,527.18,31.95,,275.52,Fee Schedule,31.95% of LA custom fee schedule,2403.94,4055,
Report,4100141,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,345.064,other,Not separately reimbursable,,31.95,,345.064,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,108.224,other,Not separately reimbursable,,,,432,other,Not separately reimbursable,2404.94,4056,
Report,4100141,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.76,other,Not separately reimbursable,,31.95,,11.76,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,108.224,other,Not separately reimbursable,,,,14.72,other,Not separately reimbursable,2405.94,4057,
Report,4100141,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,44.728,other,Not separately reimbursable,,31.95,,44.728,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.592,other,Not separately reimbursable,,,,56,other,Not separately reimbursable,2406.94,4058,
Report,4100141,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,44.728,other,Not separately reimbursable,,31.95,,44.728,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.592,other,Not separately reimbursable,,,,56,other,Not separately reimbursable,2407.94,4059,
MRI LE Joint w/ + w/o Contrast Left,4100141,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-LT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,44.728,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,44.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,14.592,case rate,pays based on per visit rate,591.08,31.95,,56,Fee Schedule,31.95% of LA custom fee schedule,2408.94,4060,
MRI Ankle w/ + w/o Contrast Left,4100141,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-LT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,44.728,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,44.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,591.08,31.95,,56,Fee Schedule,31.95% of LA custom fee schedule,2409.94,4061,
MRI Hip w/ + w/o Contrast Left,4100141,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-LT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,29.392,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,29.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.864,case rate,pays based on per visit rate,591.08,31.95,,36.8,Fee Schedule,31.95% of LA custom fee schedule,2410.94,4062,
MRI Knee w/ + w/o Contrast Left,4100141,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-LT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,14.568,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,14.568,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,17.024,case rate,pays based on per visit rate,591.08,31.95,,18.24,Fee Schedule,31.95% of LA custom fee schedule,2411.94,4063,
Report,4100142,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,182.24,other,Not separately reimbursable,,31.95,,182.24,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.712,other,Not separately reimbursable,,,,228.16,other,Not separately reimbursable,2412.94,4064,
Report,4100142,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,145.696,other,Not separately reimbursable,,31.95,,145.696,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.712,other,Not separately reimbursable,,,,182.4,other,Not separately reimbursable,2413.94,4065,
Report,4100142,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,35.152,other,Not separately reimbursable,,31.95,,117.664,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.712,other,Not separately reimbursable,,,,31.952,other,Not separately reimbursable,2414.94,4066,
Report,4100142,CDM,972,RC,73723,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,148.76,other,Not separately reimbursable,,31.95,,148.76,other,Not separately reimbursable,260.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.712,other,Not separately reimbursable,,,,186.24,other,Not separately reimbursable,2415.94,4067,
MRI LE Joint w/ + w/o Contrast Right,4100142,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-RT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,394.904,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,394.904,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,591.08,31.95,,494.4,Fee Schedule,31.95% of LA custom fee schedule,2416.94,4068,
MRI Ankle w/ + w/o Contrast Right,4100142,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-RT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,354.52,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,354.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.304,case rate,pays based on per visit rate,591.08,31.95,,443.84,Fee Schedule,31.95% of LA custom fee schedule,2417.94,4069,
MRI Hip w/ + w/o Contrast Right,4100142,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-RT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,1597.504,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,1597.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,23.712,case rate,pays based on per visit rate,591.08,31.95,,2000,Fee Schedule,31.95% of LA custom fee schedule,2418.94,4070,
MRI Knee w/ + w/o Contrast Right,4100142,CDM,610,RC,73723,HCPCS,OUTPATIENT,,,1850,1110,1-26|2-RT,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,650.28,35.15,,258.16,fee schedule,35.15% of LA custom fee schedule,591.08,31.95,,258.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,23.712,case rate,pays based on per visit rate,591.08,31.95,,323.2,Fee Schedule,31.95% of LA custom fee schedule,2419.94,4071,
Report,4100143,CDM,972,RC,73722,HCPCS,OUTPATIENT,,,245,147,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,464.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,135.472,other,Not separately reimbursable,,31.95,,135.472,other,Not separately reimbursable,217.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.712,other,Not separately reimbursable,,,,169.6,other,Not separately reimbursable,2420.94,4072,
MRI Ankle w/ Contrast Right,4100143,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-RT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,120.632,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,118.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,23.712,case rate,pays based on per visit rate,559.13,31.95,,109.656,Fee Schedule,31.95% of LA custom fee schedule,2421.94,4073,
FMC MRI Ankle w/ Contrast Right,4100143,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-RT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,120.632,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,119.624,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,23.712,case rate,pays based on per visit rate,559.13,31.95,,109.656,Fee Schedule,31.95% of LA custom fee schedule,2422.94,4074,
Report,4100144,CDM,972,RC,73722,HCPCS,OUTPATIENT,,,245,147,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,464.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,89.424,other,Not separately reimbursable,,31.95,,120.136,other,Not separately reimbursable,217.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,19.152,other,Not separately reimbursable,,,,81.28,other,Not separately reimbursable,2423.94,4075,
Report,4100144,CDM,972,RC,73722,HCPCS,OUTPATIENT,,,245,147,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,464.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,822.264,other,Not separately reimbursable,,31.95,,822.264,other,Not separately reimbursable,217.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,19.152,other,Not separately reimbursable,,,,1029.44,other,Not separately reimbursable,2424.94,4076,
Report,4100144,CDM,972,RC,73722,HCPCS,OUTPATIENT,,,245,147,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,464.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,412.536,other,Not separately reimbursable,,31.95,,412.536,other,Not separately reimbursable,217.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,19.152,other,Not separately reimbursable,,,,516.48,other,Not separately reimbursable,2425.94,4077,
MRI Ankle w/ Contrast Left,4100144,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-LT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,210.904,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,120.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,5.472,case rate,pays based on per visit rate,559.13,31.95,,191.704,Fee Schedule,31.95% of LA custom fee schedule,2426.94,4078,
MRI Knee w/ Contrast Left,4100144,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-LT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,18.144,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,18.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,559.13,31.95,,22.72,Fee Schedule,31.95% of LA custom fee schedule,2427.94,4079,
MRI Ankle w/ Contrast Bilateral,4100144,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-LT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,18.144,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,18.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,559.13,31.95,,22.72,Fee Schedule,31.95% of LA custom fee schedule,2428.94,4080,
MRI Hip w/ Contrast Left,4100144,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-LT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,335.344,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,335.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.304,case rate,pays based on per visit rate,559.13,31.95,,419.84,Fee Schedule,31.95% of LA custom fee schedule,2429.94,4081,
Report,4100145,CDM,972,RC,73722,HCPCS,OUTPATIENT,,,245,147,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,464.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.528,other,Not separately reimbursable,,31.95,,12.528,other,Not separately reimbursable,217.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.496,other,Not separately reimbursable,,,,15.68,other,Not separately reimbursable,2430.94,4082,
Report,4100145,CDM,972,RC,73722,HCPCS,OUTPATIENT,,,245,147,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,464.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,29.392,other,Not separately reimbursable,,31.95,,29.392,other,Not separately reimbursable,217.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,25.536,other,Not separately reimbursable,,,,36.8,other,Not separately reimbursable,2431.94,4083,
MRI Knee w/ Contrast Right,4100145,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-RT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,15.592,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,15.592,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.256,case rate,pays based on per visit rate,559.13,31.95,,19.52,Fee Schedule,31.95% of LA custom fee schedule,2432.94,4084,
MRI Hip w/ Contrast Right,4100145,CDM,610,RC,73722,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-RT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,1.024,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,1.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,35.872,case rate,pays based on per visit rate,559.13,31.95,,1.28,Fee Schedule,31.95% of LA custom fee schedule,2433.94,4085,
Report,4100147,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,,31.95,,1.28,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.872,other,Not separately reimbursable,,,,1.6,other,Not separately reimbursable,2434.94,4086,
Report,4100147,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.792,other,Not separately reimbursable,,31.95,,1.792,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.448,other,Not separately reimbursable,,,,2.24,other,Not separately reimbursable,2435.94,4087,
Report,4100147,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.536,other,Not separately reimbursable,,31.95,,1.536,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,1.92,other,Not separately reimbursable,2436.94,4088,
Report,4100147,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,9.712,other,Not separately reimbursable,,31.95,,9.712,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.648,other,Not separately reimbursable,,,,12.16,other,Not separately reimbursable,2437.94,4089,
MRI LE Joint w/o Contrast Left,4100147,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,2.048,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,2.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,8.816,case rate,pays based on per visit rate,527.18,31.95,,2.56,Fee Schedule,31.95% of LA custom fee schedule,2438.94,4090,
MRI Ankle w/o Contrast Left,4100147,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,203.2,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,203.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,3.952,case rate,pays based on per visit rate,527.18,31.95,,254.4,Fee Schedule,31.95% of LA custom fee schedule,2439.94,4091,
MRI Knee w/o Contrast Left,4100147,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,134.192,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,134.192,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.432,case rate,pays based on per visit rate,527.18,31.95,,168,Fee Schedule,31.95% of LA custom fee schedule,2440.94,4092,
MRI Hip w/o Contrast Left,4100147,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,586.344,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,586.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,12.464,case rate,pays based on per visit rate,527.18,31.95,,734.08,Fee Schedule,31.95% of LA custom fee schedule,2441.94,4093,
Report,4100148,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,87.928,other,Not separately reimbursable,,31.95,,87.928,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.728,other,Not separately reimbursable,,,,110.08,other,Not separately reimbursable,2442.94,4094,
Report,4100148,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,36.296,other,Not separately reimbursable,,31.95,,36.296,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.728,other,Not separately reimbursable,,,,45.44,other,Not separately reimbursable,2443.94,4095,
Report,4100148,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,26.84,other,Not separately reimbursable,,31.95,,26.84,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,33.6,other,Not separately reimbursable,2444.94,4096,
Report,4100148,CDM,972,RC,73721,HCPCS,OUTPATIENT,,,203,121.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,26.584,other,Not separately reimbursable,,31.95,,26.584,other,Not separately reimbursable,127.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,33.28,other,Not separately reimbursable,2445.94,4097,
MRI LE Joint w/o Contrast Right,4100148,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,2.304,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,2.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,20.368,case rate,pays based on per visit rate,527.18,31.95,,2.88,Fee Schedule,31.95% of LA custom fee schedule,2446.94,4098,
MRI Ankle w/o Contrast Right,4100148,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.808,case rate,pays based on per visit rate,527.18,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2447.94,4099,
MRI Knee w/o Contrast Right,4100148,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.256,case rate,pays based on per visit rate,527.18,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2448.94,4100,
MRI Hip w/o Contrast Right,4100148,CDM,610,RC,73721,HCPCS,OUTPATIENT,,,1650,990,26,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,4.088,fee schedule,35.15% of LA custom fee schedule,527.18,31.95,,4.088,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.216,case rate,pays based on per visit rate,527.18,31.95,,5.12,Fee Schedule,31.95% of LA custom fee schedule,2449.94,4101,
Report,4100150,CDM,972,RC,73720,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,497.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,192.72,other,Not separately reimbursable,,31.95,,192.72,other,Not separately reimbursable,216.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.104,other,Not separately reimbursable,,,,241.28,other,Not separately reimbursable,2450.94,4102,
Report,4100150,CDM,972,RC,73720,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,497.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,192.72,other,Not separately reimbursable,,31.95,,192.72,other,Not separately reimbursable,216.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.488,other,Not separately reimbursable,,,,241.28,other,Not separately reimbursable,2451.94,4103,
Report,4100150,CDM,972,RC,73720,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,497.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,9.2,other,Not separately reimbursable,,31.95,,9.2,other,Not separately reimbursable,216.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.768,other,Not separately reimbursable,,,,11.52,other,Not separately reimbursable,2452.94,4104,
MRI Foot w/ + w/o Contrast Left,4100150,CDM,610,RC,73720,HCPCS,OUTPATIENT,,,2135,1281,1-26|2-LT,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,2.304,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,2.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,69.672,case rate,pays based on per visit rate,682.13,31.95,,2.88,Fee Schedule,31.95% of LA custom fee schedule,2453.94,4105,
MRI Femur w/ + w/o Contrast Left,4100150,CDM,610,RC,73720,HCPCS,OUTPATIENT,,,2135,1281,1-26|2-LT,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,34.248,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,34.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,3.936,case rate,pays based on per visit rate,682.13,31.95,,42.88,Fee Schedule,31.95% of LA custom fee schedule,2454.94,4106,
MRI Tibia/Fibula w/ + w/o Contrast Left,4100150,CDM,610,RC,73720,HCPCS,OUTPATIENT,,,2135,1281,1-26|2-LT,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,49.072,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,49.072,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.104,case rate,pays based on per visit rate,682.13,31.95,,61.44,Fee Schedule,31.95% of LA custom fee schedule,2455.94,4107,
Report,4100151,CDM,972,RC,73720,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,497.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,287.296,other,Not separately reimbursable,,31.95,,287.296,other,Not separately reimbursable,216.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,52.016,other,Not separately reimbursable,,,,359.68,other,Not separately reimbursable,2456.94,4108,
Report,4100151,CDM,972,RC,73720,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,497.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.536,other,Not separately reimbursable,,31.95,,1.536,other,Not separately reimbursable,216.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.296,other,Not separately reimbursable,,,,1.92,other,Not separately reimbursable,2457.94,4109,
Report,4100151,CDM,972,RC,73720,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,497.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.536,other,Not separately reimbursable,,31.95,,1.536,other,Not separately reimbursable,216.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.472,other,Not separately reimbursable,,,,1.92,other,Not separately reimbursable,2458.94,4110,
MRI Foot w/ + w/o Contrast Right,4100151,CDM,610,RC,73720,HCPCS,OUTPATIENT,,,2135,1281,1-26|2-RT,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,4.344,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,4.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,5.168,case rate,pays based on per visit rate,682.13,31.95,,5.44,Fee Schedule,31.95% of LA custom fee schedule,2459.94,4111,
MRI Femur w/ + w/o Contrast Right,4100151,CDM,610,RC,73720,HCPCS,OUTPATIENT,,,2135,1281,1-26|2-RT,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,28.368,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,28.368,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,5.472,case rate,pays based on per visit rate,682.13,31.95,,35.52,Fee Schedule,31.95% of LA custom fee schedule,2460.94,4112,
MRI Tibia/Fibula w/ + w/o Contrast Right,4100151,CDM,610,RC,73720,HCPCS,OUTPATIENT,,,2135,1281,1-26|2-RT,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,22.24,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,22.24,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,14.16,case rate,pays based on per visit rate,682.13,31.95,,27.84,Fee Schedule,31.95% of LA custom fee schedule,2461.94,4113,
Report,4100153,CDM,972,RC,73719,HCPCS,OUTPATIENT,,,243,145.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.368,other,Not separately reimbursable,,31.95,,5.368,other,Not separately reimbursable,171.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,16.848,other,Not separately reimbursable,,,,6.72,other,Not separately reimbursable,2462.94,4114,
Report,4100153,CDM,972,RC,73719,HCPCS,OUTPATIENT,,,243,145.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.248,other,Not separately reimbursable,,31.95,,11.248,other,Not separately reimbursable,171.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.952,other,Not separately reimbursable,,,,14.08,other,Not separately reimbursable,2463.94,4115,
Report,4100153,CDM,972,RC,73719,HCPCS,OUTPATIENT,,,243,145.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.248,other,Not separately reimbursable,,31.95,,11.248,other,Not separately reimbursable,171.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.856,other,Not separately reimbursable,,,,14.08,other,Not separately reimbursable,2464.94,4116,
MRI Foot w/ Contrast Left,4100153,CDM,610,RC,73719,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-LT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,11.248,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,11.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.104,case rate,pays based on per visit rate,559.13,31.95,,14.08,Fee Schedule,31.95% of LA custom fee schedule,2465.94,4117,
MRI Femur w/ Contrast Left,4100153,CDM,610,RC,73719,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-LT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,11.248,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,11.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.608,case rate,pays based on per visit rate,559.13,31.95,,14.08,Fee Schedule,31.95% of LA custom fee schedule,2466.94,4118,
MRI Tibia/Fibula w/ Contrast Left,4100153,CDM,610,RC,73719,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-LT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,13.544,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,13.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,89.072,case rate,pays based on per visit rate,559.13,31.95,,16.96,Fee Schedule,31.95% of LA custom fee schedule,2467.94,4119,
Report,4100154,CDM,972,RC,73719,HCPCS,OUTPATIENT,,,243,145.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.112,other,Not separately reimbursable,,31.95,,5.112,other,Not separately reimbursable,171.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,70.528,other,Not separately reimbursable,,,,6.4,other,Not separately reimbursable,2468.94,4120,
Report,4100154,CDM,972,RC,73719,HCPCS,OUTPATIENT,,,243,145.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.392,other,Not separately reimbursable,,31.95,,5.392,other,Not separately reimbursable,171.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,70.528,other,Not separately reimbursable,,,,6.752,other,Not separately reimbursable,2469.94,4121,
Report,4100154,CDM,972,RC,73719,HCPCS,OUTPATIENT,,,243,145.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.544,other,Not separately reimbursable,,31.95,,13.544,other,Not separately reimbursable,171.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.776,other,Not separately reimbursable,,,,16.96,other,Not separately reimbursable,2470.94,4122,
MRI Foot w/ Contrast Right,4100154,CDM,610,RC,73719,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-RT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,3.952,case rate,pays based on per visit rate,559.13,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2471.94,4123,
MRI Femur w/ Contrast Right,4100154,CDM,610,RC,73719,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-RT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,44.216,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,44.216,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.128,case rate,pays based on per visit rate,559.13,31.95,,55.36,Fee Schedule,31.95% of LA custom fee schedule,2472.94,4124,
MRI Tibia/Fibula w/ Contrast Right,4100154,CDM,610,RC,73719,HCPCS,OUTPATIENT,,,1750,1050,1-26|2-RT,1487.5,85,,1190,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,615.13,35.15,,7.672,fee schedule,35.15% of LA custom fee schedule,559.13,31.95,,7.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.304,case rate,pays based on per visit rate,559.13,31.95,,9.6,Fee Schedule,31.95% of LA custom fee schedule,2473.94,4125,
Report,4100156,CDM,972,RC,73718,HCPCS,OUTPATIENT,,,201,120.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.368,other,Not separately reimbursable,,31.95,,5.368,other,Not separately reimbursable,146.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.976,other,Not separately reimbursable,,,,6.72,other,Not separately reimbursable,2474.94,4126,
Report,4100156,CDM,972,RC,73718,HCPCS,OUTPATIENT,,,201,120.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.536,other,Not separately reimbursable,,31.95,,1.536,other,Not separately reimbursable,146.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,19.456,other,Not separately reimbursable,,,,1.92,other,Not separately reimbursable,2475.94,4127,
Report,4100156,CDM,972,RC,73718,HCPCS,OUTPATIENT,,,201,120.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.112,other,Not separately reimbursable,,31.95,,5.112,other,Not separately reimbursable,146.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,40.432,other,Not separately reimbursable,,,,6.4,other,Not separately reimbursable,2476.94,4128,
MRI Femur w/o Contrast Left,4100156,CDM,610,RC,73718,HCPCS,OUTPATIENT,,,1372,823.2,26,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,497.144,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,497.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.256,case rate,pays based on per visit rate,438.35,31.95,,622.4,Fee Schedule,31.95% of LA custom fee schedule,2477.94,4129,
MRI Foot w/o Contrast Left,4100156,CDM,610,RC,73718,HCPCS,OUTPATIENT,,,1372,823.2,26,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,497.144,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,497.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,94.24,case rate,pays based on per visit rate,438.35,31.95,,622.4,Fee Schedule,31.95% of LA custom fee schedule,2478.94,4130,
MRI Tibia/Fibula w/o Contrast Left,4100156,CDM,610,RC,73718,HCPCS,OUTPATIENT,,,1372,823.2,26,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,587.88,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,587.88,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,3.952,case rate,pays based on per visit rate,438.35,31.95,,736,Fee Schedule,31.95% of LA custom fee schedule,2479.94,4131,
Report,4100157,CDM,972,RC,73718,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,47.288,other,Not separately reimbursable,,31.95,,47.288,other,Not separately reimbursable,146.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.232,other,Not separately reimbursable,,,,59.2,other,Not separately reimbursable,2480.94,4132,
Report,4100157,CDM,972,RC,73718,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,255.6,other,Not separately reimbursable,,31.95,,255.6,other,Not separately reimbursable,146.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,320,other,Not separately reimbursable,2481.94,4133,
Report,4100157,CDM,972,RC,73718,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.536,other,Not separately reimbursable,,31.95,,1.536,other,Not separately reimbursable,146.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.208,other,Not separately reimbursable,,,,1.92,other,Not separately reimbursable,2482.94,4134,
MRI Femur w/o Contrast Right,4100157,CDM,610,RC,73718,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-RT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,32.464,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,32.464,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,5.776,case rate,pays based on per visit rate,438.35,31.95,,40.64,Fee Schedule,31.95% of LA custom fee schedule,2483.94,4135,
MRI Foot w/o Contrast Right,4100157,CDM,610,RC,73718,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-RT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,3.064,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,3.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,4.256,case rate,pays based on per visit rate,438.35,31.95,,3.84,Fee Schedule,31.95% of LA custom fee schedule,2484.94,4136,
MRI Tibia/Fibula w/o Contrast Right,4100157,CDM,610,RC,73718,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-RT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,7.528,case rate,pays based on per visit rate,438.35,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2485.94,4137,
Report,4100158,CDM,972,RC,72158,HCPCS,OUTPATIENT,,,345,207,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,467.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,125.248,other,Not separately reimbursable,,31.95,,125.248,other,Not separately reimbursable,194.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.64,other,Not separately reimbursable,,,,156.8,other,Not separately reimbursable,2486.94,4138,
MRI Spine Lumbar w/ + w/o Contrast,4100158,CDM,610,RC,72158,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,135.472,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,135.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,56.848,case rate,pays based on per visit rate,682.13,31.95,,169.6,Fee Schedule,31.95% of LA custom fee schedule,2487.94,4139,
MRI Spine Lumbar w/ + w/o Contrast,4100158,CDM,610,RC,72158,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,138.024,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,138.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.304,case rate,pays based on per visit rate,682.13,31.95,,172.8,Fee Schedule,31.95% of LA custom fee schedule,2488.94,4140,
Report,4100159,CDM,972,RC,72148,HCPCS,OUTPATIENT,,,222,133.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,278.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,21.728,other,Not separately reimbursable,,31.95,,21.728,other,Not separately reimbursable,111.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,48.608,other,Not separately reimbursable,,,,27.2,other,Not separately reimbursable,2489.94,4141,
MRI Spine Lumbar w/o Contrast,4100159,CDM,610,RC,72148,HCPCS,OUTPATIENT,,,1550,930,26,1317.5,85,,1054,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,544.83,35.15,,4.088,fee schedule,35.15% of LA custom fee schedule,495.23,31.95,,4.088,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,38,case rate,pays based on per visit rate,495.23,31.95,,5.12,Fee Schedule,31.95% of LA custom fee schedule,2490.94,4142,
Report,4100160,CDM,972,RC,70543,HCPCS,OUTPATIENT,,,321,192.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,495.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.024,other,Not separately reimbursable,,31.95,,1.024,other,Not separately reimbursable,218.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,2491.94,4143,
MRI Face Neck Orbit w/ + w/o Contrast,4100160,CDM,610,RC,70543,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,37.088,case rate,pays based on per visit rate,682.13,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2492.94,4144,
MRI Face Neck Orbit w/ + w/o Contrast Tech,4100160,CDM,610,RC,70543,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,51.12,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,51.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.736,case rate,pays based on per visit rate,682.13,31.95,,64,Fee Schedule,31.95% of LA custom fee schedule,2493.94,4145,
MRI Face Neck Orbit w/ + w/o Contrast Profee,4100160,CDM,972,RC,70543,HCPCS,OUTPATIENT,,,321,192.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,495.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,132.912,other,Not separately reimbursable,,31.95,,132.912,other,Not separately reimbursable,218.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,166.4,other,Not separately reimbursable,2494.94,4146,
Report,4100161,CDM,972,RC,70542,HCPCS,OUTPATIENT,,,243,145.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,394.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.624,other,Not separately reimbursable,,31.95,,5.624,other,Not separately reimbursable,176.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,7.04,other,Not separately reimbursable,2495.94,4147,
MRI Face Neck Orbit w/ Contrast,4100161,CDM,610,RC,70542,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.944,case rate,pays based on per visit rate,543.15,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,2496.94,4148,
Report,4100162,CDM,972,RC,70540,HCPCS,OUTPATIENT,,,200,120,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,331.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.576,other,Not separately reimbursable,,31.95,,3.576,other,Not separately reimbursable,149.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.272,other,Not separately reimbursable,,,,4.48,other,Not separately reimbursable,2497.94,4149,
MRI Face Neck Orbit w/o Contrast,4100162,CDM,610,RC,70540,HCPCS,OUTPATIENT,,,1300,780,26,1105,85,,884,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,456.95,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,415.35,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,12.464,case rate,pays based on per visit rate,415.35,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2498.94,4150,
Report,4100163,CDM,972,RC,72197,HCPCS,OUTPATIENT,,,341,204.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,499.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.856,other,Not separately reimbursable,,31.95,,4.856,other,Not separately reimbursable,214.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,6.08,other,Not separately reimbursable,2499.94,4151,
MRI Pelvis w/ + w/o Contrast,4100163,CDM,610,RC,72197,HCPCS,OUTPATIENT,,,1800,1080,26,1530,85,,1224,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,575.1,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,27.056,case rate,pays based on per visit rate,575.1,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,2500.94,4152,
Report,4100164,CDM,972,RC,72196,HCPCS,OUTPATIENT,,,261,156.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,395.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.024,other,Not separately reimbursable,,31.95,,1.024,other,Not separately reimbursable,171.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,1.28,other,Not separately reimbursable,2501.94,4153,
MRI Pelvis w/ Contrast,4100164,CDM,610,RC,72196,HCPCS,OUTPATIENT,,,1400,840,26,1190,85,,952,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,492.1,35.15,,7.672,fee schedule,35.15% of LA custom fee schedule,447.3,31.95,,7.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,12.464,case rate,pays based on per visit rate,447.3,31.95,,9.6,Fee Schedule,31.95% of LA custom fee schedule,2502.94,4154,
Report,4100165,CDM,972,RC,72195,HCPCS,OUTPATIENT,,,218,130.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,338.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,4.6,other,Not separately reimbursable,,31.95,,4.6,other,Not separately reimbursable,146.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.248,other,Not separately reimbursable,,,,5.76,other,Not separately reimbursable,2503.94,4155,
MRI Pelvis w/o Contrast,4100165,CDM,610,RC,72195,HCPCS,OUTPATIENT,,,1372,823.2,26,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,10.336,case rate,pays based on per visit rate,438.35,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,2504.94,4156,
Report,4100166,CDM,972,RC,76390,HCPCS,OUTPATIENT,,,300,180,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,539.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.224,other,Not separately reimbursable,,31.95,,10.224,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,8.272,other,Not separately reimbursable,,,,12.8,other,Not separately reimbursable,2505.94,4157,
MRI Spectroscopy,4100166,CDM,610,RC,76390,HCPCS,OUTPATIENT,,,1150,690,26,977.5,85,,782,Percent of total billed charges,85% of total billed charges,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1273.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,404.23,35.15,,6.392,fee schedule,35.15% of LA custom fee schedule,367.43,31.95,,6.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,8.816,case rate,pays based on per visit rate,367.43,31.95,,8,Fee Schedule,31.95% of LA custom fee schedule,2506.94,4158,
Report,4100167,CDM,972,RC,72157,HCPCS,OUTPATIENT,,,345,207,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,470.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,28.88,other,Not separately reimbursable,,31.95,,28.88,other,Not separately reimbursable,195.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,36.16,other,Not separately reimbursable,2507.94,4159,
MRI Spine Thoracic w/ + w/o Contrast,4100167,CDM,610,RC,72157,HCPCS,OUTPATIENT,,,2135,1281,26,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,71.056,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,71.056,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.824,case rate,pays based on per visit rate,682.13,31.95,,88.96,Fee Schedule,31.95% of LA custom fee schedule,2508.94,4160,
Report,4100168,CDM,972,RC,72147,HCPCS,OUTPATIENT,,,268,160.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,399.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,173.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.776,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2509.94,4161,
MRI Spine Thoracic w/ Contrast,4100168,CDM,610,RC,72147,HCPCS,OUTPATIENT,,,1775,1065,26,1508.75,85,,1207,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,623.91,35.15,,43.456,fee schedule,35.15% of LA custom fee schedule,567.11,31.95,,43.456,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,5.776,case rate,pays based on per visit rate,567.11,31.95,,54.4,Fee Schedule,31.95% of LA custom fee schedule,2510.94,4162,
Report,4100169,CDM,972,RC,72146,HCPCS,OUTPATIENT,,,221,132.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,278.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.248,other,Not separately reimbursable,,31.95,,11.248,other,Not separately reimbursable,111.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.296,other,Not separately reimbursable,,,,14.08,other,Not separately reimbursable,2511.94,4163,
MRI Spine Thoracic w/o Contrast,4100169,CDM,610,RC,72146,HCPCS,OUTPATIENT,,,1500,900,26,1275,85,,1020,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,527.25,35.15,,10.224,fee schedule,35.15% of LA custom fee schedule,479.25,31.95,,10.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,8.208,case rate,pays based on per visit rate,479.25,31.95,,12.8,Fee Schedule,31.95% of LA custom fee schedule,2512.94,4164,
Report,4100170,CDM,972,RC,70336,HCPCS,OUTPATIENT,,,220,132,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,376.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,178.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,258.824,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2513.94,4165,
MRI TMJ,4100170,CDM,610,RC,70336,HCPCS,OUTPATIENT,,,1675,1005,26,1423.75,85,,1139,Percent of total billed charges,85% of total billed charges,946.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,946.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,588.76,35.15,,3.32,fee schedule,35.15% of LA custom fee schedule,535.16,31.95,,3.32,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.912,case rate,pays based on per visit rate,535.16,31.95,,4.16,Fee Schedule,31.95% of LA custom fee schedule,2514.94,4166,
Report,4100172,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.304,other,Not separately reimbursable,,31.95,,25.304,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,123.096,other,Not separately reimbursable,,,,31.68,other,Not separately reimbursable,2515.94,4167,
Report,4100172,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.464,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2516.94,4168,
Report,4100172,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.264,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2517.94,4169,
Report,4100172,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,35.848,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2518.94,4170,
MRI UE Joint w/ Contrast Left,4100172,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-LT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,4.344,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,4.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.304,case rate,pays based on per visit rate,607.05,31.95,,5.44,Fee Schedule,31.95% of LA custom fee schedule,2519.94,4171,
MRI Wrist w/ Contrast Left,4100172,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-LT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,607.05,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,2520.94,4172,
MRI Elbow w/ Contrast Left,4100172,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-LT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,26.84,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,26.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.912,case rate,pays based on per visit rate,607.05,31.95,,33.6,Fee Schedule,31.95% of LA custom fee schedule,2521.94,4173,
MRI Shoulder w/ Contrast Left,4100172,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-LT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,25.56,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,25.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,14.072,case rate,pays based on per visit rate,607.05,31.95,,32,Fee Schedule,31.95% of LA custom fee schedule,2522.94,4174,
Report,4100173,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.136,other,Not separately reimbursable,,31.95,,6.136,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.256,other,Not separately reimbursable,,,,7.68,other,Not separately reimbursable,2523.94,4175,
Report,4100173,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,38.344,other,Not separately reimbursable,,31.95,,38.344,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.432,other,Not separately reimbursable,,,,48,other,Not separately reimbursable,2524.94,4176,
Report,4100173,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,99.688,other,Not separately reimbursable,,31.95,,99.688,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,124.8,other,Not separately reimbursable,2525.94,4177,
Report,4100173,CDM,972,RC,73222,HCPCS,OUTPATIENT,,,244,146.4,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,216.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.336,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2526.94,4178,
MRI UE Joint w/ Contrast Right,4100173,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-RT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,35.784,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,35.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.128,case rate,pays based on per visit rate,607.05,31.95,,44.8,Fee Schedule,31.95% of LA custom fee schedule,2527.94,4179,
MRI Wrist w/ Contrast Right,4100173,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-RT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,607.05,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2528.94,4180,
MRI Elbow w/ Contrast Right,4100173,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-RT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,4.6,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,4.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,11.552,case rate,pays based on per visit rate,607.05,31.95,,5.76,Fee Schedule,31.95% of LA custom fee schedule,2529.94,4181,
MRI Shoulder w/ Contrast Right,4100173,CDM,610,RC,73222,HCPCS,OUTPATIENT,,,1900,1140,1-26|2-RT,1615,85,,1292,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,667.85,35.15,,17.64,fee schedule,35.15% of LA custom fee schedule,607.05,31.95,,17.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,35.024,case rate,pays based on per visit rate,607.05,31.95,,22.08,Fee Schedule,31.95% of LA custom fee schedule,2530.94,4182,
Report,4100175,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.672,other,Not separately reimbursable,,31.95,,7.672,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,105.064,other,Not separately reimbursable,,,,9.6,other,Not separately reimbursable,2531.94,4183,
Report,4100175,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,56.232,other,Not separately reimbursable,,31.95,,56.232,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,68.4,other,Not separately reimbursable,,,,70.4,other,Not separately reimbursable,2532.94,4184,
Report,4100175,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,87.928,other,Not separately reimbursable,,31.95,,87.928,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,57.456,other,Not separately reimbursable,,,,110.08,other,Not separately reimbursable,2533.94,4185,
Report,4100175,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,92.016,other,Not separately reimbursable,,31.95,,92.016,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.952,other,Not separately reimbursable,,,,115.2,other,Not separately reimbursable,2534.94,4186,
MRI UE Joint w/ + w/o Contrast Left,4100175,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-LT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,145.184,fee schedule,35.15% of LA custom fee schedule,639,31.95,,145.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,6.384,case rate,pays based on per visit rate,639,31.95,,181.76,Fee Schedule,31.95% of LA custom fee schedule,2535.94,4187,
MRI Wrist w/ + w/o Contrast Left,4100175,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-LT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,217.768,fee schedule,35.15% of LA custom fee schedule,639,31.95,,217.768,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,6.08,case rate,pays based on per visit rate,639,31.95,,272.64,Fee Schedule,31.95% of LA custom fee schedule,2536.94,4188,
MRI Elbow w/ + w/o Contrast Left,4100175,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-LT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,290.36,fee schedule,35.15% of LA custom fee schedule,639,31.95,,290.36,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,8.72,case rate,pays based on per visit rate,639,31.95,,363.52,Fee Schedule,31.95% of LA custom fee schedule,2537.94,4189,
MRI Shoulder w/ + w/o Contrast Left,4100175,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-LT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,435.544,fee schedule,35.15% of LA custom fee schedule,639,31.95,,435.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,120.848,case rate,pays based on per visit rate,639,31.95,,545.28,Fee Schedule,31.95% of LA custom fee schedule,2538.94,4190,
Report,4100176,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,435.544,other,Not separately reimbursable,,31.95,,435.544,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,425.6,other,Not separately reimbursable,,,,545.28,other,Not separately reimbursable,2539.94,4191,
Report,4100176,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,109.912,other,Not separately reimbursable,,31.95,,109.912,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,137.6,other,Not separately reimbursable,2540.94,4192,
Report,4100176,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,9.456,other,Not separately reimbursable,,31.95,,9.456,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,11.84,other,Not separately reimbursable,2541.94,4193,
Report,4100176,CDM,972,RC,73223,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.16,other,Not separately reimbursable,,31.95,,7.16,other,Not separately reimbursable,261.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,8.96,other,Not separately reimbursable,2542.94,4194,
MRI UE Joint w/ + w/o Contrast Right,4100176,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-RT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,3.192,fee schedule,35.15% of LA custom fee schedule,639,31.95,,3.192,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,38.304,case rate,pays based on per visit rate,639,31.95,,4,Fee Schedule,31.95% of LA custom fee schedule,2543.94,4195,
MRI Wrist w/ + w/o Contrast Right,4100176,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-RT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,74.128,fee schedule,35.15% of LA custom fee schedule,639,31.95,,74.128,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,174.496,case rate,pays based on per visit rate,639,31.95,,92.8,Fee Schedule,31.95% of LA custom fee schedule,2544.94,4196,
MRI Elbow w/ + w/o Contrast Right,4100176,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-RT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,35.272,fee schedule,35.15% of LA custom fee schedule,639,31.95,,35.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,174.496,case rate,pays based on per visit rate,639,31.95,,44.16,Fee Schedule,31.95% of LA custom fee schedule,2545.94,4197,
MRI Shoulder w/ + w/o Contrast Right,4100176,CDM,610,RC,73223,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-RT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,8.944,fee schedule,35.15% of LA custom fee schedule,639,31.95,,8.944,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.432,case rate,pays based on per visit rate,639,31.95,,11.2,Fee Schedule,31.95% of LA custom fee schedule,2546.94,4198,
Report,4100178,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.648,other,Not separately reimbursable,,31.95,,6.648,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,30.4,other,Not separately reimbursable,,,,8.32,other,Not separately reimbursable,2547.94,4199,
Report,4100178,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.032,other,Not separately reimbursable,,31.95,,13.032,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.912,other,Not separately reimbursable,,,,16.32,other,Not separately reimbursable,2548.94,4200,
Report,4100178,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.912,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2549.94,4201,
Report,4100178,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.112,other,Not separately reimbursable,,31.95,,5.112,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.912,other,Not separately reimbursable,,,,6.4,other,Not separately reimbursable,2550.94,4202,
MRI UE Joint w/o Contrast Left,4100178,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,9.968,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,9.968,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,34.312,case rate,pays based on per visit rate,543.15,31.95,,12.48,Fee Schedule,31.95% of LA custom fee schedule,2551.94,4203,
MRI Wrist w/o Contrast Left,4100178,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,9.968,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,9.968,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,25.536,case rate,pays based on per visit rate,543.15,31.95,,12.48,Fee Schedule,31.95% of LA custom fee schedule,2552.94,4204,
MRI Elbow w/o Contrast Left,4100178,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,9.968,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,9.968,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.912,case rate,pays based on per visit rate,543.15,31.95,,12.48,Fee Schedule,31.95% of LA custom fee schedule,2553.94,4205,
MRI Shoulder w/o Contrast Left,4100178,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,11.248,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,11.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,11.488,case rate,pays based on per visit rate,543.15,31.95,,14.08,Fee Schedule,31.95% of LA custom fee schedule,2554.94,4206,
Report,4100179,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,35.272,other,Not separately reimbursable,,31.95,,35.272,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,44.16,other,Not separately reimbursable,2555.94,4207,
Report,4100179,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,24.536,other,Not separately reimbursable,,31.95,,24.536,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.6,other,Not separately reimbursable,,,,30.72,other,Not separately reimbursable,2556.94,4208,
Report,4100179,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,22.496,other,Not separately reimbursable,,31.95,,22.496,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.208,other,Not separately reimbursable,,,,28.16,other,Not separately reimbursable,2557.94,4209,
Report,4100179,CDM,972,RC,73221,HCPCS,OUTPATIENT,,,204,122.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,148.76,other,Not separately reimbursable,,31.95,,148.76,other,Not separately reimbursable,127.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,186.24,other,Not separately reimbursable,2558.94,4210,
MRI UE Joint w/o Contrast Right,4100179,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,148.76,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,148.76,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,0.608,case rate,pays based on per visit rate,543.15,31.95,,186.24,Fee Schedule,31.95% of LA custom fee schedule,2559.94,4211,
MRI Wrist w/o Contrast Right,4100179,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,3.192,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,3.192,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,543.15,31.95,,4,Fee Schedule,31.95% of LA custom fee schedule,2560.94,4212,
MRI Elbow w/o Contrast Right,4100179,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,281.16,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,281.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,2.736,case rate,pays based on per visit rate,543.15,31.95,,352,Fee Schedule,31.95% of LA custom fee schedule,2561.94,4213,
MRI Shoulder w/o Contrast Right,4100179,CDM,610,RC,73221,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,6.648,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,6.648,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,297.92,case rate,pays based on per visit rate,543.15,31.95,,8.32,Fee Schedule,31.95% of LA custom fee schedule,2562.94,4214,
Report,4100180,CDM,972,RC,73219,HCPCS,OUTPATIENT,,,246,147.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,46.264,other,Not separately reimbursable,,31.95,,46.264,other,Not separately reimbursable,233.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,408.576,other,Not separately reimbursable,,,,57.92,other,Not separately reimbursable,2563.94,4215,
Report,4100180,CDM,972,RC,73219,HCPCS,OUTPATIENT,,,246,147.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.832,other,Not separately reimbursable,,31.95,,3.832,other,Not separately reimbursable,233.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.824,other,Not separately reimbursable,,,,4.8,other,Not separately reimbursable,2564.94,4216,
Report,4100180,CDM,972,RC,73219,HCPCS,OUTPATIENT,,,246,147.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,61.344,other,Not separately reimbursable,,31.95,,61.344,other,Not separately reimbursable,233.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,76.8,other,Not separately reimbursable,2565.94,4217,
Report,4100180,CDM,972,RC,73219,HCPCS,OUTPATIENT,,,246,147.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,233.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2566.94,4218,
MRI Forearm w/ Contrast Left,4100180,CDM,610,RC,73219,HCPCS,OUTPATIENT,,,1700,1020,1-26|2-LT,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,56.232,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,56.232,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,40.736,case rate,pays based on per visit rate,543.15,31.95,,70.4,Fee Schedule,31.95% of LA custom fee schedule,2567.94,4219,
MRI Forearm w/ Contrast Right,4100180,CDM,610,RC,73219,HCPCS,OUTPATIENT,,,1700,1020,1-26|2-LT,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,4.856,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,4.856,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,40.736,case rate,pays based on per visit rate,543.15,31.95,,6.08,Fee Schedule,31.95% of LA custom fee schedule,2568.94,4220,
MRI Hand w/ Contrast Right,4100180,CDM,610,RC,73219,HCPCS,OUTPATIENT,,,1700,1020,1-26|2-LT,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,40.736,case rate,pays based on per visit rate,543.15,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2569.94,4221,
MRI Humerus w/ Contrast Right,4100180,CDM,610,RC,73219,HCPCS,OUTPATIENT,,,1700,1020,1-26|2-LT,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,40.736,case rate,pays based on per visit rate,543.15,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2570.94,4222,
Report,4100181,CDM,972,RC,73219,HCPCS,OUTPATIENT,,,246,147.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,233.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,40.736,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2571.94,4223,
Report,4100181,CDM,972,RC,73219,HCPCS,OUTPATIENT,,,246,147.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,233.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,40.736,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2572.94,4224,
MRI Hand w/ Contrast Left,4100181,CDM,610,RC,73219,HCPCS,OUTPATIENT,,,1700,1020,1-26|2-LT,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,40.736,case rate,pays based on per visit rate,543.15,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2573.94,4225,
MRI Humerus w/ Contrast Left,4100181,CDM,610,RC,73219,HCPCS,OUTPATIENT,,,1700,1020,1-26|2-LT,1445,85,,1156,Percent of total billed charges,85% of total billed charges,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1157.29,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,543.15,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,40.736,case rate,pays based on per visit rate,543.15,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2574.94,4226,
Report,4100184,CDM,972,RC,73220,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,607.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,282.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,65.664,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2575.94,4227,
Report,4100184,CDM,972,RC,73220,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,607.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,3.192,other,Not separately reimbursable,,31.95,,3.192,other,Not separately reimbursable,282.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,65.664,other,Not separately reimbursable,,,,4,other,Not separately reimbursable,2576.94,4228,
Report,4100184,CDM,972,RC,73220,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,607.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.672,other,Not separately reimbursable,,31.95,,7.672,other,Not separately reimbursable,282.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,65.664,other,Not separately reimbursable,,,,9.6,other,Not separately reimbursable,2577.94,4229,
MRI Forearm w/ + w/o Contrast Left,4100184,CDM,610,RC,73220,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-LT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,639,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,65.664,case rate,pays based on per visit rate,639,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2578.94,4230,
MRI Hand w/ + w/o Contrast Left,4100184,CDM,610,RC,73220,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-LT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,639,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,65.664,case rate,pays based on per visit rate,639,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2579.94,4231,
MRI Humerus w/ + w/o Contrast Left,4100184,CDM,610,RC,73220,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-LT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,23.624,fee schedule,35.15% of LA custom fee schedule,639,31.95,,121.408,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,65.664,case rate,pays based on per visit rate,639,31.95,,21.472,Fee Schedule,31.95% of LA custom fee schedule,2580.94,4232,
Report,4100185,CDM,972,RC,73220,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,607.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,30.672,other,Not separately reimbursable,,31.95,,30.672,other,Not separately reimbursable,282.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.328,other,Not separately reimbursable,,,,38.4,other,Not separately reimbursable,2581.94,4233,
Report,4100185,CDM,972,RC,73220,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,607.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,37.064,other,Not separately reimbursable,,31.95,,37.064,other,Not separately reimbursable,282.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.328,other,Not separately reimbursable,,,,46.4,other,Not separately reimbursable,2582.94,4234,
Report,4100185,CDM,972,RC,73220,HCPCS,OUTPATIENT,,,323,193.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,607.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,33.736,other,Not separately reimbursable,,31.95,,33.736,other,Not separately reimbursable,282.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.328,other,Not separately reimbursable,,,,42.24,other,Not separately reimbursable,2583.94,4235,
MRI Forearm w/ + w/o Contrast Right,4100185,CDM,610,RC,73220,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-RT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,4.088,fee schedule,35.15% of LA custom fee schedule,639,31.95,,4.088,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,17.328,case rate,pays based on per visit rate,639,31.95,,5.12,Fee Schedule,31.95% of LA custom fee schedule,2584.94,4236,
MRI Hand w/ + w/o Contrast Right,4100185,CDM,610,RC,73220,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-RT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,35.272,fee schedule,35.15% of LA custom fee schedule,639,31.95,,35.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,87.856,case rate,pays based on per visit rate,639,31.95,,44.16,Fee Schedule,31.95% of LA custom fee schedule,2585.94,4237,
MRI Humerus w/ + w/o Contrast Right,4100185,CDM,610,RC,73220,HCPCS,OUTPATIENT,,,2000,1200,1-26|2-RT,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,100.96,fee schedule,35.15% of LA custom fee schedule,639,31.95,,100.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,87.856,case rate,pays based on per visit rate,639,31.95,,126.4,Fee Schedule,31.95% of LA custom fee schedule,2586.94,4238,
FMC MR INJ GADOTERIDOL/PROHANCE PER ML,4100186,CDM,254,RC,A9576,HCPCS,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,2.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1.92,31.95,,60.576,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,60.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,17.328,percent of total billed charges,38% of total billed charges,2.4,40,,75.84,percent of total billed charges,40% of total billed charges,2587.94,4239,
Report,4100187,CDM,972,RC,73218,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,85.488,other,Not separately reimbursable,,31.95,,121.408,other,Not separately reimbursable,201,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.328,other,Not separately reimbursable,,,,77.704,other,Not separately reimbursable,2588.94,4240,
Report,4100187,CDM,972,RC,73218,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,240.264,other,Not separately reimbursable,,31.95,,240.264,other,Not separately reimbursable,201,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.592,other,Not separately reimbursable,,,,300.8,other,Not separately reimbursable,2589.94,4241,
Report,4100187,CDM,972,RC,73218,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,172.376,other,Not separately reimbursable,,31.95,,121.408,other,Not separately reimbursable,201,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.592,other,Not separately reimbursable,,,,156.68,other,Not separately reimbursable,2590.94,4242,
MRI Forearm w/o Contrast Left,4100187,CDM,610,RC,73218,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-LT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,199.936,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,121.408,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,1.52,case rate,pays based on per visit rate,438.35,31.95,,181.728,Fee Schedule,31.95% of LA custom fee schedule,2591.94,4243,
MRI Hand w/o Contrast Left,4100187,CDM,610,RC,73218,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-LT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,95.048,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,121.664,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,5.728,case rate,pays based on per visit rate,438.35,31.95,,86.392,Fee Schedule,31.95% of LA custom fee schedule,2592.94,4244,
MRI Humerus w/o Contrast Left,4100187,CDM,610,RC,73218,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-LT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,40.776,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,121.664,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,76.608,case rate,pays based on per visit rate,438.35,31.95,,37.064,Fee Schedule,31.95% of LA custom fee schedule,2593.94,4245,
Report,4100188,CDM,972,RC,73218,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,41.336,other,Not separately reimbursable,,31.95,,121.92,other,Not separately reimbursable,201,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,37.576,other,Not separately reimbursable,2594.94,4246,
Report,4100188,CDM,972,RC,73218,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,41.336,other,Not separately reimbursable,,31.95,,121.92,other,Not separately reimbursable,201,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,37.576,other,Not separately reimbursable,2595.94,4247,
Report,4100188,CDM,972,RC,73218,HCPCS,OUTPATIENT,,,201,120.6,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,296.664,other,Not separately reimbursable,,31.95,,121.92,other,Not separately reimbursable,201,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.08,other,Not separately reimbursable,,,,269.656,other,Not separately reimbursable,2596.94,4248,
MRI Forearm w/o Contrast Right,4100188,CDM,610,RC,73218,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-RT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,6.08,case rate,pays based on per visit rate,438.35,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,2597.94,4249,
MRI Hand w/o Contrast Right,4100188,CDM,610,RC,73218,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-RT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,503.536,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,503.536,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,6.992,case rate,pays based on per visit rate,438.35,31.95,,630.4,Fee Schedule,31.95% of LA custom fee schedule,2598.94,4250,
MRI Humerus w/o Contrast Right,4100188,CDM,610,RC,73218,HCPCS,OUTPATIENT,,,1372,823.2,1-26|2-RT,1166.2,85,,932.96,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,482.26,35.15,,321.696,fee schedule,35.15% of LA custom fee schedule,438.35,31.95,,123.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,6.992,case rate,pays based on per visit rate,438.35,31.95,,292.408,Fee Schedule,31.95% of LA custom fee schedule,2599.94,4251,
MRI Pituitary Gland w/ + w/o Contrast,4100189,CDM,610,RC,70553,HCPCS,OUTPATIENT,,,2135,1281,,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,42.184,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,123.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,243.2,case rate,pays based on per visit rate,682.13,31.95,,38.344,Fee Schedule,31.95% of LA custom fee schedule,2600.94,4252,
Report,4100189,CDM,972,RC,70553,HCPCS,OUTPATIENT,,,343,205.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,465.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,62.624,other,Not separately reimbursable,,31.95,,62.624,other,Not separately reimbursable,193.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,59.584,other,Not separately reimbursable,,,,78.4,other,Not separately reimbursable,2601.94,4253,
Report,4100190,CDM,972,RC,78315,HCPCS,OUTPATIENT,,,151,90.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,437.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,357.84,other,Not separately reimbursable,,31.95,,357.84,other,Not separately reimbursable,151,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.6,other,Not separately reimbursable,,,,448,other,Not separately reimbursable,2602.94,4254,
NM Bone Three Phase Study,4100190,CDM,341,RC,78315,HCPCS,OUTPATIENT,,,950,570,26,807.5,85,,646,Percent of total billed charges,85% of total billed charges,552.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,552.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,333.93,35.15,,51.12,fee schedule,35.15% of LA custom fee schedule,303.53,31.95,,51.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,7.6,case rate,pays based on per visit rate,303.53,31.95,,64,Fee Schedule,31.95% of LA custom fee schedule,2603.94,4255,
FMC NM ADENOSINE  6 MG,4100193,CDM,636,RC,J0150,HCPCS,OUTPATIENT,,,375,225,TC,318.75,85,,255,Percent of total billed charges,85% of total billed charges,187.5,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,187.5,50,,150,percent of total billed charges,50% of total billed charges,131.81,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,105.44,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,54.112,other,Not separately reimbursable,119.81,31.95,,160,percent of total billed charges,31.95% of total billed charges,2604.94,4256,
FMC NM AMINOPHYLLIN,4100194,CDM,636,RC,J0280,HCPCS,OUTPATIENT,,,15,9,TC,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,15.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,15.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,5.27,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,105.44,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,0.912,other,Not separately reimbursable,4.79,31.95,,160,percent of total billed charges,31.95% of total billed charges,2605.94,4257,
FMC NM ATROPINE SULFATE INJ T,4100195,CDM,636,RC,J0461,HCPCS,OUTPATIENT,,,17,10.2,TC,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,0.14,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.14,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,5.98,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,5.43,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,1.216,other,Not separately reimbursable,5.43,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,2606.94,4258,
FMC NM BISICATE,4100196,CDM,636,RC,A9557,HCPCS,OUTPATIENT,,,700,420,TC,595,85,,476,Percent of total billed charges,85% of total billed charges,548.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,548.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,246.05,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,105.44,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,1.216,other,Not separately reimbursable,223.65,31.95,,160,percent of total billed charges,31.95% of total billed charges,2607.94,4259,
MRI IAC w/ + w/o Contrast,4100199,CDM,610,RC,70553,HCPCS,OUTPATIENT,,,2135,1281,,1814.75,85,,1451.8,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,750.45,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,682.13,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,8.512,case rate,pays based on per visit rate,682.13,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,2608.94,4260,
Report,4100199,CDM,972,RC,70553,HCPCS,OUTPATIENT,,,343,205.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,465.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,127.8,other,Not separately reimbursable,,31.95,,127.8,other,Not separately reimbursable,193.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,160,other,Not separately reimbursable,2609.94,4261,
FMC NM CCK,4100200,CDM,636,RC,J2805,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,193.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,193.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,105.44,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,12.712,other,Not separately reimbursable,95.85,31.95,,160,percent of total billed charges,31.95% of total billed charges,2610.94,4262,
FMC NM CERETEC,4100202,CDM,636,RC,A9521,HCPCS,OUTPATIENT,,,1050,630,TC,892.5,85,,714,Percent of total billed charges,85% of total billed charges,2255.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2255.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,369.08,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,105.44,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,134.976,other,Not separately reimbursable,335.48,31.95,,160,percent of total billed charges,31.95% of total billed charges,2611.94,4263,
FMC NM CROFAB,4100203,CDM,636,RC,J0840,HCPCS,OUTPATIENT,,,8058.9,4835.34,TC,6850.07,85,,5480.056,Percent of total billed charges,85% of total billed charges,3120.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3120.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2832.7,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,2574.82,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,5194.48,100,,134.976,case rate,pays based on per visit rate,2574.82,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,2612.94,4264,
FMC NM DOBUTAMINE,4100204,CDM,636,RC,J1250,HCPCS,OUTPATIENT,,,150,90,TC,127.5,85,,102,Percent of total billed charges,85% of total billed charges,14.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,105.44,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,13.376,other,Not separately reimbursable,47.93,31.95,,160,percent of total billed charges,31.95% of total billed charges,2613.94,4265,
FMC NM DTPA AEROSOL,4100205,CDM,636,RC,A9567,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,20,percent of total billed charges,50% of total billed charges,17.58,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,105.44,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,13.376,other,Not separately reimbursable,15.98,31.95,,160,percent of total billed charges,31.95% of total billed charges,2614.94,4266,
FMC NM EPOETIN ALFA VL 1000 U,4100206,CDM,636,RC,,,OUTPATIENT,,,55.94,33.564,TC,47.55,85,,38.04,Percent of total billed charges,85% of total billed charges,27.97,50,,22.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.97,50,,22.376,percent of total billed charges,50% of total billed charges,17.87,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,17.87,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,0.608,other,Not separately reimbursable,22.38,40,,40,percent of total billed charges,40% of total billed charges,2615.94,4267,
FMC NM GALLIUM-67 PER MCI,4100207,CDM,636,RC,A9556,HCPCS,OUTPATIENT,,,100,60,TC,85,85,,68,Percent of total billed charges,85% of total billed charges,199.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.15,35.15,,39.616,percent of total billed charges,35.15% of total billed charges,105.75,31.95,,39.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,25.16,other,Not separately reimbursable,31.95,31.95,,49.6,percent of total billed charges,31.95% of total billed charges,2616.94,4268,
Report,4100208,CDM,972,RC,78264,HCPCS,OUTPATIENT,,,118,70.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,422.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,35.784,other,Not separately reimbursable,,31.95,,35.784,other,Not separately reimbursable,118,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.6,other,Not separately reimbursable,,,,44.8,other,Not separately reimbursable,2617.94,4269,
NM Gastric Emptying Study,4100208,CDM,341,RC,78264,HCPCS,OUTPATIENT,,,1296,777.6,26,1101.6,85,,881.28,Percent of total billed charges,85% of total billed charges,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,455.54,35.15,,15.336,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,750,100,,13.952,case rate,pays based on per visit rate,414.07,31.95,,19.2,percent of total billed charges,31.95% of total billed charges,2618.94,4270,
Report,4100209,CDM,972,RC,78472,HCPCS,OUTPATIENT,,,143,85.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,290.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,143,100,,,fee schedule,100% of CMS physician fee schedule,,,,21.416,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2619.94,4271,
NM Cardiac Blood Pool Gated Rest/Stress,4100209,CDM,341,RC,78472,HCPCS,OUTPATIENT,,,1050,630,26,892.5,85,,714,Percent of total billed charges,85% of total billed charges,637.95,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,637.95,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,369.08,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,335.48,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,18.24,case rate,pays based on per visit rate,335.48,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2620.94,4272,
NM GI Bleed Scan,4100210,CDM,341,RC,78278,HCPCS,OUTPATIENT,,,1296,777.6,TC,1101.6,85,,881.28,Percent of total billed charges,85% of total billed charges,561.86,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,561.86,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,455.54,35.15,,8.944,fee schedule,35.15% of LA custom fee schedule,414.07,31.95,,8.944,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,12.872,case rate,pays based on per visit rate,414.07,31.95,,11.2,Fee Schedule,31.95% of LA custom fee schedule,2621.94,4273,
Report,4100210,CDM,972,RC,78278,HCPCS,OUTPATIENT,,,148,88.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,440.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.272,other,Not separately reimbursable,,31.95,,12.272,other,Not separately reimbursable,148,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.872,other,Not separately reimbursable,,,,15.36,other,Not separately reimbursable,2622.94,4274,
Report,4100211,CDM,972,RC,78496,HCPCS,OUTPATIENT,,,73,43.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,57.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.032,other,Not separately reimbursable,,31.95,,12.528,other,Not separately reimbursable,16.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.688,other,Not separately reimbursable,,,,6.392,other,Not separately reimbursable,2623.94,4275,
NM Cardiac Blood Pool Gated Single,4100211,CDM,341,RC,78496,HCPCS,OUTPATIENT,,,500,300,26,425,85,,340,Percent of total billed charges,85% of total billed charges,279.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,279.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,310.552,fee schedule,35.15% of LA custom fee schedule,159.75,31.95,,310.552,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,12.248,case rate,pays based on per visit rate,159.75,31.95,,388.8,Fee Schedule,31.95% of LA custom fee schedule,2624.94,4276,
Report,4100212,CDM,972,RC,78227,HCPCS,OUTPATIENT,,,133,79.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,561.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,310.552,other,Not separately reimbursable,,31.95,,310.552,other,Not separately reimbursable,133,100,,,fee schedule,100% of CMS physician fee schedule,,,,16.112,other,Not separately reimbursable,,,,388.8,other,Not separately reimbursable,2625.94,4277,
NM Hepatobiliary Duct System Imaging,4100212,CDM,341,RC,78227,HCPCS,OUTPATIENT,,,1491,894.6,26,1267.35,85,,1013.88,Percent of total billed charges,85% of total billed charges,1166.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1166.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,524.09,35.15,,287.552,fee schedule,35.15% of LA custom fee schedule,476.37,31.95,,287.552,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,8.384,case rate,pays based on per visit rate,476.37,31.95,,360,Fee Schedule,31.95% of LA custom fee schedule,2626.94,4278,
FMC NM I-123 100UCI DX CAP,4100213,CDM,343,RC,A9516,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,281.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,281.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.05,35.15,,389.792,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,389.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,10.64,other,Not separately reimbursable,53.68,31.95,,488,percent of total billed charges,31.95% of total billed charges,2627.94,4279,
"FMC NM I-131 CAP, EA ADD MCI",4100214,CDM,636,RC,A9517,HCPCS,OUTPATIENT,,,50,30,TC,42.5,85,,34,Percent of total billed charges,85% of total billed charges,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.58,35.15,,42.176,fee schedule,35.15% of LA custom fee schedule,15.98,31.95,,42.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,59.33,100,,2.432,case rate,pays based on per visit rate,15.98,31.95,,52.8,Fee Schedule,31.95% of LA custom fee schedule,2628.94,4280,
"FMC NM I-131 CAP, INITIAL 1-5",4100215,CDM,636,RC,A9517,HCPCS,OUTPATIENT,,,250,150,TC,212.5,85,,170,Percent of total billed charges,85% of total billed charges,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,114.512,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,114.512,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,59.33,100,,21.28,case rate,pays based on per visit rate,79.88,31.95,,143.36,Fee Schedule,31.95% of LA custom fee schedule,2629.94,4281,
"FMC NM I-131 PER MCI SOL,RX U",4100216,CDM,636,RC,A9517,HCPCS,OUTPATIENT,,,292,175.2,TC,248.2,85,,198.56,Percent of total billed charges,85% of total billed charges,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,147.736,fee schedule,35.15% of LA custom fee schedule,93.29,31.95,,147.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,59.33,100,,67.184,case rate,pays based on per visit rate,93.29,31.95,,184.96,Fee Schedule,31.95% of LA custom fee schedule,2630.94,4282,
"FMC NM I-131 PER UCI, DX",4100217,CDM,636,RC,A9517,HCPCS,OUTPATIENT,,,50,30,TC,42.5,85,,34,Percent of total billed charges,85% of total billed charges,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.58,35.15,,147.736,fee schedule,35.15% of LA custom fee schedule,15.98,31.95,,147.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,59.33,100,,20.52,case rate,pays based on per visit rate,15.98,31.95,,184.96,Fee Schedule,31.95% of LA custom fee schedule,2631.94,4283,
"FMC NM I-131 SOL, EA ADD. MCI",4100218,CDM,636,RC,A9530,HCPCS,OUTPATIENT,,,60,36,TC,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,21.09,35.15,,8.72,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,56.78,100,,0.912,case rate,pays based on per visit rate,19.17,31.95,,7.92,percent of total billed charges,31.95% of total billed charges,2632.94,4284,
FMC NM INDIUM IN111 DTPA PER,4100219,CDM,343,RC,A9548,HCPCS,OUTPATIENT,,,1425,855,TC,1211.25,85,,969,Percent of total billed charges,85% of total billed charges,1152,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1152,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,500.89,35.15,,8.72,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,126.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,13.68,other,Not separately reimbursable,455.29,31.95,,7.92,percent of total billed charges,31.95% of total billed charges,2633.94,4285,
FMC NM INDIUM IN111 OXINE PER,4100220,CDM,343,RC,A9547,HCPCS,OUTPATIENT,,,1350,810,TC,1147.5,85,,918,Percent of total billed charges,85% of total billed charges,2637.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2637.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,474.53,35.15,,11.504,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,5.32,other,Not separately reimbursable,431.33,31.95,,14.4,percent of total billed charges,31.95% of total billed charges,2634.94,4286,
FMC NM INDIUM IN111 PENTETREO,4100221,CDM,343,RC,A9572,HCPCS,OUTPATIENT,,,3000,1800,TC,2550,85,,2040,Percent of total billed charges,85% of total billed charges,7373.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,7373.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1054.5,35.15,,51.888,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,51.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,18.24,other,Not separately reimbursable,958.5,31.95,,64.96,percent of total billed charges,31.95% of total billed charges,2635.94,4287,
NM Bowel Image (Meckel`s),4100222,CDM,341,RC,78290,HCPCS,OUTPATIENT,,,1296,777.6,TC,1101.6,85,,881.28,Percent of total billed charges,85% of total billed charges,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,455.54,35.15,,549.544,fee schedule,35.15% of LA custom fee schedule,414.07,31.95,,549.544,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,59.584,case rate,pays based on per visit rate,414.07,31.95,,688,Fee Schedule,31.95% of LA custom fee schedule,2636.94,4288,
Report,4100222,CDM,972,RC,78290,HCPCS,OUTPATIENT,,,101,60.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,416.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,613.44,other,Not separately reimbursable,,31.95,,613.44,other,Not separately reimbursable,101,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.376,other,Not separately reimbursable,,,,768,other,Not separately reimbursable,2637.94,4289,
FMC NM IV PERSANTIN 10 MG,4100223,CDM,636,RC,J1245,HCPCS,OUTPATIENT,,,150,90,TC,127.5,85,,102,Percent of total billed charges,85% of total billed charges,5.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,549.544,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,549.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,4.256,other,Not separately reimbursable,47.93,31.95,,688,percent of total billed charges,31.95% of total billed charges,2638.94,4290,
Report,4100224,CDM,972,RC,78709,HCPCS,OUTPATIENT,,,202,121.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,466.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.904,other,Not separately reimbursable,,31.95,,126.776,other,Not separately reimbursable,202,100,,,fee schedule,100% of CMS physician fee schedule,,,,25.536,other,Not separately reimbursable,,,,21.728,other,Not separately reimbursable,2639.94,4291,
NM Kidney Imaging w/ Flow w/ + w/o Pharm,4100224,CDM,341,RC,78709,HCPCS,OUTPATIENT,,,1669,1001.4,26,1418.65,85,,1134.92,Percent of total billed charges,85% of total billed charges,564.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,564.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,586.65,35.15,,12.016,fee schedule,35.15% of LA custom fee schedule,533.25,31.95,,12.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,647.52,case rate,pays based on per visit rate,533.25,31.95,,15.04,Fee Schedule,31.95% of LA custom fee schedule,2640.94,4292,
Report,4100225,CDM,972,RC,78708,HCPCS,OUTPATIENT,,,178,106.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,227.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,17.432,other,Not separately reimbursable,,31.95,,127.288,other,Not separately reimbursable,105.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.248,other,Not separately reimbursable,,,,15.848,other,Not separately reimbursable,2641.94,4293,
NM Kidney Imaging w/ Flow w/ Pharm,4100225,CDM,341,RC,78708,HCPCS,OUTPATIENT,,,1669,1001.4,26,1418.65,85,,1134.92,Percent of total billed charges,85% of total billed charges,564.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,564.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,586.65,35.15,,328.448,fee schedule,35.15% of LA custom fee schedule,533.25,31.95,,328.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,666.464,case rate,pays based on per visit rate,533.25,31.95,,411.2,Fee Schedule,31.95% of LA custom fee schedule,2642.94,4294,
Report,4100226,CDM,972,RC,78707,HCPCS,OUTPATIENT,,,139,83.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,295.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,21.728,other,Not separately reimbursable,,31.95,,21.728,other,Not separately reimbursable,139,100,,,fee schedule,100% of CMS physician fee schedule,,,,333.232,other,Not separately reimbursable,,,,27.2,other,Not separately reimbursable,2643.94,4295,
NM Kidney Imaging w/ Flow w/o Pharm,4100226,CDM,341,RC,78707,HCPCS,OUTPATIENT,,,1669,1001.4,26,1418.65,85,,1134.92,Percent of total billed charges,85% of total billed charges,515.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,515.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,586.65,35.15,,10.736,fee schedule,35.15% of LA custom fee schedule,533.25,31.95,,10.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,128.576,case rate,pays based on per visit rate,533.25,31.95,,13.44,Fee Schedule,31.95% of LA custom fee schedule,2644.94,4296,
Report,4100228,CDM,972,RC,78701,HCPCS,OUTPATIENT,,,71,42.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,273.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,85.768,other,Not separately reimbursable,,31.95,,1278,other,Not separately reimbursable,71,100,,,fee schedule,100% of CMS physician fee schedule,,,,45.448,other,Not separately reimbursable,,,,77.96,other,Not separately reimbursable,2645.94,4297,
NM Kidney Imaging w/ Vascular Flow,4100228,CDM,340,RC,78701,HCPCS,OUTPATIENT,,,1668,1000.8,26,1417.8,85,,1134.24,Percent of total billed charges,85% of total billed charges,497.17,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,497.17,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,586.3,35.15,,159.752,fee schedule,35.15% of LA custom fee schedule,532.93,31.95,,159.752,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,122.576,case rate,pays based on per visit rate,532.93,31.95,,200,Fee Schedule,31.95% of LA custom fee schedule,2646.94,4298,
FMC NM KINEVAC SINCALIDE INJECTION,4100229,CDM,636,RC,J2805,HCPCS,OUTPATIENT,,,349,209.4,,296.65,85,,237.32,Percent of total billed charges,85% of total billed charges,193.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,193.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.67,35.15,,31.952,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,38.2,other,Not separately reimbursable,111.51,31.95,,40,percent of total billed charges,31.95% of total billed charges,2647.94,4299,
NM Liver/Spleen Imaging Static Only,4100231,CDM,341,RC,78215,HCPCS,OUTPATIENT,,,1491,894.6,TC,1267.35,85,,1013.88,Percent of total billed charges,85% of total billed charges,586.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,524.09,35.15,,84.352,fee schedule,35.15% of LA custom fee schedule,476.37,31.95,,84.352,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,35.952,case rate,pays based on per visit rate,476.37,31.95,,105.6,Fee Schedule,31.95% of LA custom fee schedule,2648.94,4300,
Report,4100231,CDM,972,RC,78215,HCPCS,OUTPATIENT,,,72,43.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,245.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,24.28,other,Not separately reimbursable,,31.95,,24.28,other,Not separately reimbursable,72,100,,,fee schedule,100% of CMS physician fee schedule,,,,37.72,other,Not separately reimbursable,,,,30.4,other,Not separately reimbursable,2649.94,4301,
Report,4100232,CDM,972,RC,78216,HCPCS,OUTPATIENT,,,84,50.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,162.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,81.792,other,Not separately reimbursable,,31.95,,81.792,other,Not separately reimbursable,84,100,,,fee schedule,100% of CMS physician fee schedule,,,,53.728,other,Not separately reimbursable,,,,102.4,other,Not separately reimbursable,2650.94,4302,
NM Liver/Spleen Imaging w/ Vascular Flow,4100232,CDM,341,RC,78216,HCPCS,OUTPATIENT,,,1491,894.6,26,1267.35,85,,1013.88,Percent of total billed charges,85% of total billed charges,586.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,524.09,35.15,,96.616,fee schedule,35.15% of LA custom fee schedule,476.37,31.95,,96.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,56.64,case rate,pays based on per visit rate,476.37,31.95,,120.96,Fee Schedule,31.95% of LA custom fee schedule,2651.94,4303,
NM Pulmonary Vent/Perf Quantitative,4100234,CDM,341,RC,78598,HCPCS,OUTPATIENT,,,1724,1034.4,TC,1465.4,85,,1172.32,Percent of total billed charges,85% of total billed charges,758.4,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,758.4,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,605.99,35.15,,34.504,fee schedule,35.15% of LA custom fee schedule,550.82,31.95,,34.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,45.432,case rate,pays based on per visit rate,550.82,31.95,,43.2,Fee Schedule,31.95% of LA custom fee schedule,2652.94,4304,
Report,4100234,CDM,972,RC,78598,HCPCS,OUTPATIENT,,,124,74.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,385.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.544,other,Not separately reimbursable,,31.95,,13.544,other,Not separately reimbursable,124,100,,,fee schedule,100% of CMS physician fee schedule,,,,50.92,other,Not separately reimbursable,,,,16.96,other,Not separately reimbursable,2653.94,4305,
NM Pulmonary Function Test,4100235,CDM,340,RC,78597,HCPCS,OUTPATIENT,,,1175,705,TC,998.75,85,,799,Percent of total billed charges,85% of total billed charges,467.98,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,467.98,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,413.01,35.15,,139.304,fee schedule,35.15% of LA custom fee schedule,375.41,31.95,,139.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,50.92,case rate,pays based on per visit rate,375.41,31.95,,174.4,Fee Schedule,31.95% of LA custom fee schedule,2654.94,4306,
Report,4100235,CDM,972,RC,78597,HCPCS,OUTPATIENT,,,108,64.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,254.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,134.192,other,Not separately reimbursable,,31.95,,134.192,other,Not separately reimbursable,108,100,,,fee schedule,100% of CMS physician fee schedule,,,,39.032,other,Not separately reimbursable,,,,168,other,Not separately reimbursable,2655.94,4307,
Report,4100236,CDM,972,RC,78580,HCPCS,OUTPATIENT,,,108,64.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,301.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,110.928,other,Not separately reimbursable,,31.95,,110.928,other,Not separately reimbursable,108,100,,,fee schedule,100% of CMS physician fee schedule,,,,39.032,other,Not separately reimbursable,,,,138.88,other,Not separately reimbursable,2656.94,4308,
NM Pulmonary Perfusion Imaging,4100236,CDM,341,RC,78580,HCPCS,OUTPATIENT,,,1225,735,26,1041.25,85,,833,Percent of total billed charges,85% of total billed charges,451.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,451.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,430.59,35.15,,110.928,fee schedule,35.15% of LA custom fee schedule,391.39,31.95,,110.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,21.296,case rate,pays based on per visit rate,391.39,31.95,,138.88,Fee Schedule,31.95% of LA custom fee schedule,2657.94,4309,
Report,4100237,CDM,972,RC,78582,HCPCS,OUTPATIENT,,,158,94.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,423.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.008,other,Not separately reimbursable,,31.95,,23.008,other,Not separately reimbursable,158,100,,,fee schedule,100% of CMS physician fee schedule,,,,58.512,other,Not separately reimbursable,,,,28.8,other,Not separately reimbursable,2658.94,4310,
NM Pulmonary Perfusion w/ Ventilation,4100237,CDM,341,RC,78582,HCPCS,OUTPATIENT,,,1724,1034.4,26,1465.4,85,,1172.32,Percent of total billed charges,85% of total billed charges,782.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,782.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,605.99,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,550.82,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,28.648,case rate,pays based on per visit rate,550.82,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2659.94,4311,
FMC NM MAA  PER VIAL,4100238,CDM,636,RC,A9540,HCPCS,OUTPATIENT,,,96,57.6,,81.6,85,,65.28,Percent of total billed charges,85% of total billed charges,36.88,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,36.88,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,33.74,35.15,,235.152,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,235.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,29.208,other,Not separately reimbursable,30.67,31.95,,294.4,percent of total billed charges,31.95% of total billed charges,2660.94,4312,
FMC NM MAG3 PER MCI,4100239,CDM,636,RC,A9562,HCPCS,OUTPATIENT,,,360,216,TC,306,85,,244.8,Percent of total billed charges,85% of total billed charges,1143.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1143.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,189.808,percent of total billed charges,35.15% of total billed charges,106.07,31.95,,1380.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,50.92,other,Not separately reimbursable,115.02,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,2661.94,4313,
FMC NM MEBROFENIN PER VIAL,4100240,CDM,343,RC,A9537,HCPCS,OUTPATIENT,,,102,61.2,,86.7,85,,69.36,Percent of total billed charges,85% of total billed charges,11.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,11.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.85,35.15,,268.384,percent of total billed charges,35.15% of total billed charges,106.22,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,174.152,other,Not separately reimbursable,32.59,31.95,,336,percent of total billed charges,31.95% of total billed charges,2662.94,4314,
Report,4100241,CDM,972,RC,78305,HCPCS,OUTPATIENT,,,122,73.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,354.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,54.952,other,Not separately reimbursable,,31.95,,54.952,other,Not separately reimbursable,122,100,,,fee schedule,100% of CMS physician fee schedule,,,,174.152,other,Not separately reimbursable,,,,68.8,other,Not separately reimbursable,2663.94,4315,
NM Bone Imaging Limited Multiple Areas,4100241,CDM,341,RC,78305,HCPCS,OUTPATIENT,,,1296,777.6,26,1101.6,85,,881.28,Percent of total billed charges,85% of total billed charges,542.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,542.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,455.54,35.15,,9.712,fee schedule,35.15% of LA custom fee schedule,414.07,31.95,,9.712,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,4.216,case rate,pays based on per visit rate,414.07,31.95,,12.16,Fee Schedule,31.95% of LA custom fee schedule,2664.94,4316,
Report,4100242,CDM,972,RC,78452,HCPCS,OUTPATIENT,,,235,141,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,597.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,9.712,other,Not separately reimbursable,,31.95,,9.712,other,Not separately reimbursable,235,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.392,other,Not separately reimbursable,,,,12.16,other,Not separately reimbursable,2665.94,4317,
NM Myocardial Perf Multi Rest/Stress,4100242,CDM,341,RC,78452,HCPCS,OUTPATIENT,,,4615,2769,26,3922.75,85,,3138.2,Percent of total billed charges,85% of total billed charges,1238.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1238.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1622.17,35.15,,9.712,fee schedule,35.15% of LA custom fee schedule,1474.49,31.95,,9.712,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,6.08,case rate,pays based on per visit rate,1474.49,31.95,,12.16,Fee Schedule,31.95% of LA custom fee schedule,2666.94,4318,
Report,4100243,CDM,972,RC,78451,HCPCS,OUTPATIENT,,,200,120,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,430.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.272,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2667.94,4319,
NM Myocardial Perf Single,4100243,CDM,341,RC,78451,HCPCS,OUTPATIENT,,,4615,2769,26,3922.75,85,,3138.2,Percent of total billed charges,85% of total billed charges,780.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,780.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1622.17,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,1474.49,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,3.848,case rate,pays based on per visit rate,1474.49,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2668.94,4320,
FMC NM NUCLEAR RX ORAL ADMIN,4100245,CDM,342,RC,79005,HCPCS,OUTPATIENT,,,1024,614.4,TC,870.4,85,,696.32,Percent of total billed charges,85% of total billed charges,527.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,527.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,359.94,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,327.17,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,11.424,case rate,pays based on per visit rate,327.17,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2669.94,4321,
Report,4100246,CDM,972,RC,78070,HCPCS,OUTPATIENT,,,118,70.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,377.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,118,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.384,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2670.94,4322,
NM Parathyroid Study,4100246,CDM,341,RC,78070,HCPCS,OUTPATIENT,,,1148,688.8,26,975.8,85,,780.64,Percent of total billed charges,85% of total billed charges,477.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,477.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,403.52,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,366.79,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,2.232,case rate,pays based on per visit rate,366.79,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2671.94,4323,
Report,4100247,CDM,972,RC,78230,HCPCS,OUTPATIENT,,,66,39.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,220.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,66,100,,,fee schedule,100% of CMS physician fee schedule,,,,27.36,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2672.94,4324,
NM Salivary Gland Function Study,4100247,CDM,341,RC,78230,HCPCS,OUTPATIENT,,,1296,777.6,26,1101.6,85,,881.28,Percent of total billed charges,85% of total billed charges,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,455.54,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,414.07,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,374.936,case rate,pays based on per visit rate,414.07,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2673.94,4325,
FMC NM PERTECHNETATE,4100248,CDM,636,RC,A9512,HCPCS,OUTPATIENT,,,102,61.2,,86.7,85,,69.36,Percent of total billed charges,85% of total billed charges,1.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.85,35.15,,16.616,percent of total billed charges,35.15% of total billed charges,106.22,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,0.432,other,Not separately reimbursable,32.59,31.95,,20.8,percent of total billed charges,31.95% of total billed charges,2674.94,4326,
FMC NM PYROPHOSPHATE  PER VIA,4100249,CDM,636,RC,A9538,HCPCS,OUTPATIENT,,,90,54,TC,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,23.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,23.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.64,35.15,,6.648,percent of total billed charges,35.15% of total billed charges,106.22,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,0.432,other,Not separately reimbursable,28.76,31.95,,8.32,percent of total billed charges,31.95% of total billed charges,2675.94,4327,
FMC RETAVASE HALF KIT (1 VIAL),4100250,CDM,636,RC,J2993,HCPCS,OUTPATIENT,,,8610.45,5166.27,TC,7318.88,85,,5855.104,Percent of total billed charges,85% of total billed charges,4244.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4244.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3026.57,35.15,,6.648,percent of total billed charges,35.15% of total billed charges,107.03,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6839.85,100,,304,case rate,pays based on per visit rate,2751.04,31.95,,8.32,percent of total billed charges,31.95% of total billed charges,2676.94,4328,
Report,4100251,CDM,972,RC,78232,HCPCS,OUTPATIENT,,,62,37.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,129.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.648,other,Not separately reimbursable,,31.95,,6.648,other,Not separately reimbursable,62,100,,,fee schedule,100% of CMS physician fee schedule,,,,31.352,other,Not separately reimbursable,,,,8.32,other,Not separately reimbursable,2677.94,4329,
NM Salivary Gland Imaging,4100251,CDM,340,RC,78232,HCPCS,OUTPATIENT,,,1296,777.6,26,1101.6,85,,881.28,Percent of total billed charges,85% of total billed charges,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,512.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,455.54,35.15,,6.648,percent of total billed charges,35.15% of total billed charges,107.35,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,750,100,,6.584,case rate,pays based on per visit rate,414.07,31.95,,8.32,percent of total billed charges,31.95% of total billed charges,2678.94,4330,
FMC NM SESTAMIBI PER DOSE,4100252,CDM,636,RC,A9500,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,166.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,166.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,23.008,percent of total billed charges,35.15% of total billed charges,107.35,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,12.464,other,Not separately reimbursable,95.85,31.95,,28.8,percent of total billed charges,31.95% of total billed charges,2679.94,4331,
Report,4100254,CDM,972,RC,78300,HCPCS,OUTPATIENT,,,94,56.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,290.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.008,other,Not separately reimbursable,,31.95,,23.008,other,Not separately reimbursable,94,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.464,other,Not separately reimbursable,,,,28.8,other,Not separately reimbursable,2680.94,4332,
NM Bone Imaging Limited,4100254,CDM,341,RC,78300,HCPCS,OUTPATIENT,,,1296,777.6,26,1101.6,85,,881.28,Percent of total billed charges,85% of total billed charges,542.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,542.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,455.54,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,414.07,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,4.368,case rate,pays based on per visit rate,414.07,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2681.94,4333,
FMC NM SULFUR COLLOID PER DOS,4100255,CDM,636,RC,A9541,HCPCS,OUTPATIENT,,,152,91.2,TC,129.2,85,,103.36,Percent of total billed charges,85% of total billed charges,78.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,53.43,35.15,,13.032,percent of total billed charges,35.15% of total billed charges,108.63,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,4.368,other,Not separately reimbursable,48.56,31.95,,16.32,percent of total billed charges,31.95% of total billed charges,2682.94,4334,
Report,4100256,CDM,972,RC,78579,HCPCS,OUTPATIENT,,,71,42.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,234.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.032,other,Not separately reimbursable,,31.95,,13.032,other,Not separately reimbursable,71,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.92,other,Not separately reimbursable,,,,16.32,other,Not separately reimbursable,2683.94,4335,
NM Pulmonary Ventilation Aerosol Single,4100256,CDM,341,RC,78579,HCPCS,OUTPATIENT,,,1331,798.6,26,1131.35,85,,905.08,Percent of total billed charges,85% of total billed charges,436.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,436.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,467.85,35.15,,13.032,fee schedule,35.15% of LA custom fee schedule,425.25,31.95,,13.032,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,3.84,case rate,pays based on per visit rate,425.25,31.95,,16.32,Fee Schedule,31.95% of LA custom fee schedule,2684.94,4336,
FMC NM TC99- MYOVIEW  UNIT DO,4100258,CDM,636,RC,A9502,HCPCS,OUTPATIENT,,,450,270,TC,382.5,85,,306,Percent of total billed charges,85% of total billed charges,143.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,143.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,10.736,percent of total billed charges,35.15% of total billed charges,108.63,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,4.056,other,Not separately reimbursable,143.78,31.95,,13.44,percent of total billed charges,31.95% of total billed charges,2685.94,4337,
FMC TECHNECTUIM TC99M CARDIOLITE,4100259,CDM,343,RC,A9500,HCPCS,OUTPATIENT,,,150,90,TC,127.5,85,,102,Percent of total billed charges,85% of total billed charges,166.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,166.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,10.736,percent of total billed charges,35.15% of total billed charges,108.95,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,5.28,other,Not separately reimbursable,47.93,31.95,,13.44,percent of total billed charges,31.95% of total billed charges,2686.94,4338,
Report,4100260,CDM,972,RC,78761,HCPCS,OUTPATIENT,,,108,64.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,267.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.736,other,Not separately reimbursable,,31.95,,10.736,other,Not separately reimbursable,108,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.216,other,Not separately reimbursable,,,,13.44,other,Not separately reimbursable,2687.94,4339,
NM Testicular Imaging w/ Vascular Flow,4100260,CDM,341,RC,78761,HCPCS,OUTPATIENT,,,1669,1001.4,26,1418.65,85,,1134.92,Percent of total billed charges,85% of total billed charges,497.17,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,497.17,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,586.65,35.15,,23.256,fee schedule,35.15% of LA custom fee schedule,533.25,31.95,,23.256,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,334.4,case rate,pays based on per visit rate,533.25,31.95,,29.12,Fee Schedule,31.95% of LA custom fee schedule,2688.94,4340,
FMC NM THALLIUM PER MCI,4100261,CDM,636,RC,A9505,HCPCS,OUTPATIENT,,,156,93.6,TC,132.6,85,,106.08,Percent of total billed charges,85% of total billed charges,99.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.83,35.15,,20.96,percent of total billed charges,35.15% of total billed charges,110.23,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,0.872,other,Not separately reimbursable,49.84,31.95,,26.24,percent of total billed charges,31.95% of total billed charges,2689.94,4341,
Report,4100262,CDM,972,RC,78013,HCPCS,OUTPATIENT,,,54,32.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,241.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.96,other,Not separately reimbursable,,31.95,,20.96,other,Not separately reimbursable,54,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.232,other,Not separately reimbursable,,,,26.24,other,Not separately reimbursable,2690.94,4342,
NM Thyroid Imaging Only,4100262,CDM,341,RC,78013,HCPCS,OUTPATIENT,,,560,336,26,476,85,,380.8,Percent of total billed charges,85% of total billed charges,501.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,196.84,35.15,,20.96,fee schedule,35.15% of LA custom fee schedule,178.92,31.95,,20.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,3.576,case rate,pays based on per visit rate,178.92,31.95,,26.24,Fee Schedule,31.95% of LA custom fee schedule,2691.94,4343,
NM Thyroid Imaging Uptake,4100263,CDM,341,RC,78012,HCPCS,OUTPATIENT,,,775,465,TC,658.75,85,,527,Percent of total billed charges,85% of total billed charges,192.67,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,192.67,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,272.41,35.15,,20.96,fee schedule,35.15% of LA custom fee schedule,247.61,31.95,,20.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,86.64,case rate,pays based on per visit rate,247.61,31.95,,26.24,Fee Schedule,31.95% of LA custom fee schedule,2692.94,4344,
Report,4100263,CDM,972,RC,78012,HCPCS,OUTPATIENT,,,29,17.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,102.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.272,other,Not separately reimbursable,,31.95,,12.272,other,Not separately reimbursable,29,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,15.36,other,Not separately reimbursable,2693.94,4345,
NM Thyroid Uptake and Scan,4100264,CDM,340,RC,78014,HCPCS,OUTPATIENT,,,870,522,TC,739.5,85,,591.6,Percent of total billed charges,85% of total billed charges,571.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,571.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,305.81,35.15,,12.272,fee schedule,35.15% of LA custom fee schedule,277.97,31.95,,12.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,0.608,case rate,pays based on per visit rate,277.97,31.95,,15.36,Fee Schedule,31.95% of LA custom fee schedule,2694.94,4346,
Report,4100264,CDM,972,RC,78014,HCPCS,OUTPATIENT,,,73,43.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,303.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.272,other,Not separately reimbursable,,31.95,,12.272,other,Not separately reimbursable,73,100,,,fee schedule,100% of CMS physician fee schedule,,,,91.2,other,Not separately reimbursable,,,,15.36,other,Not separately reimbursable,2695.94,4347,
Report,4100265,CDM,972,RC,78800,HCPCS,OUTPATIENT,,,99,59.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,247.25,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.304,other,Not separately reimbursable,,31.95,,25.304,other,Not separately reimbursable,99,100,,,fee schedule,100% of CMS physician fee schedule,,,,361.76,other,Not separately reimbursable,,,,31.68,other,Not separately reimbursable,2696.94,4348,
NM Tumor Localization Spect,4100265,CDM,341,RC,78800,HCPCS,OUTPATIENT,,,1532,919.2,26,1302.2,85,,1041.76,Percent of total billed charges,85% of total billed charges,563,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,563,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,538.5,35.15,,25.304,fee schedule,35.15% of LA custom fee schedule,489.47,31.95,,25.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,562.4,case rate,pays based on per visit rate,489.47,31.95,,31.68,Fee Schedule,31.95% of LA custom fee schedule,2697.94,4349,
FMC NM ULTRA TAG PER MCI,4100266,CDM,636,RC,A9560,HCPCS,OUTPATIENT,,,800,480,,680,85,,544,Percent of total billed charges,85% of total billed charges,137.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,137.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,281.2,35.15,,25.304,percent of total billed charges,35.15% of total billed charges,110.23,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,468.16,other,Not separately reimbursable,255.6,31.95,,31.68,percent of total billed charges,31.95% of total billed charges,2698.94,4350,
Report,4100267,CDM,972,RC,78458,HCPCS,OUTPATIENT,,,133,79.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,261.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,132.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,101.232,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2699.94,4351,
NM Venous Thrombosis Imaging Bilateral,4100267,CDM,341,RC,78458,HCPCS,OUTPATIENT,,,1272,763.2,26,1081.2,85,,864.96,Percent of total billed charges,85% of total billed charges,386.67,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,386.67,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.11,35.15,,19.168,percent of total billed charges,35.15% of total billed charges,110.23,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,750,100,,489.44,case rate,pays based on per visit rate,406.4,31.95,,24,percent of total billed charges,31.95% of total billed charges,2700.94,4352,
Report,4100268,CDM,972,RC,78457,HCPCS,OUTPATIENT,,,133,79.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,243.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,105.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2701.94,4353,
NM Venous Thrombosis Imaging Left,4100268,CDM,341,RC,78457,HCPCS,OUTPATIENT,,,1272,763.2,1-26|2-LT,1081.2,85,,864.96,Percent of total billed charges,85% of total billed charges,307.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,307.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.11,35.15,,15.336,percent of total billed charges,35.15% of total billed charges,110.23,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,750,100,,3.04,case rate,pays based on per visit rate,406.4,31.95,,19.2,percent of total billed charges,31.95% of total billed charges,2702.94,4354,
Report,4100269,CDM,972,RC,78457,HCPCS,OUTPATIENT,,,133,79.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,243.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,105.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.6,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2703.94,4355,
NM Venous Thrombosis Imaging Right,4100269,CDM,341,RC,78457,HCPCS,OUTPATIENT,,,1272,763.2,1-26|2-RT,1081.2,85,,864.96,Percent of total billed charges,85% of total billed charges,307.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,307.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.11,35.15,,15.336,percent of total billed charges,35.15% of total billed charges,110.23,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,750,100,,16.72,case rate,pays based on per visit rate,406.4,31.95,,19.2,percent of total billed charges,31.95% of total billed charges,2704.94,4356,
Report,4100270,CDM,972,RC,78306,HCPCS,OUTPATIENT,,,126,75.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,381.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,126,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.128,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2705.94,4357,
NM Bone Imaging Whole Body,4100270,CDM,341,RC,78306,HCPCS,OUTPATIENT,,,900,540,26,765,85,,612,Percent of total billed charges,85% of total billed charges,542.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,542.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,287.55,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,6.384,case rate,pays based on per visit rate,287.55,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2706.94,4358,
FMC PROCRIT 2000 UNIT/1 ML,4100271,CDM,636,RC,J0885,HCPCS,OUTPATIENT,,,86.85,52.11,TC,73.82,85,,59.056,Percent of total billed charges,85% of total billed charges,10.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,30.53,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,27.75,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,19.83,100,,4.28,case rate,pays based on per visit rate,27.75,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2707.94,4359,
FMC TC99M LABELED RBC=<30 MCI,4100272,CDM,343,RC,A9560,HCPCS,OUTPATIENT,,,150,90,TC,127.5,85,,102,Percent of total billed charges,85% of total billed charges,137.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,137.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,16.616,percent of total billed charges,35.15% of total billed charges,110.23,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,2.88,other,Not separately reimbursable,47.93,31.95,,20.8,percent of total billed charges,31.95% of total billed charges,2708.94,4360,
US Unlisted Procedure,4100273,CDM,402,RC,76999,HCPCS,OUTPATIENT,,,300,180,1-TC|2-TC,255,85,,204,Percent of total billed charges,85% of total billed charges,136.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,136.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,95.85,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,2.472,case rate,pays based on per visit rate,95.85,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2709.94,4361,
Report,4100274,CDM,972,RC,76700,HCPCS,OUTPATIENT,,,121,72.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,69.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.24,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2710.94,4362,
US Abdomen Complete,4100274,CDM,402,RC,76700,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,11.032,case rate,pays based on per visit rate,123.33,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2711.94,4363,
Report,4100275,CDM,972,RC,76705,HCPCS,OUTPATIENT,,,89,53.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,114.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,52.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.096,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2712.94,4364,
US Abdomen Limited,4100275,CDM,402,RC,76705,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,29.184,case rate,pays based on per visit rate,123.33,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2713.94,4365,
US RUQ,4100275,CDM,402,RC,76705,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,4.784,case rate,pays based on per visit rate,123.33,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2714.94,4366,
US RUQ,4100275,CDM,402,RC,76705,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,6.592,case rate,pays based on per visit rate,123.33,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2715.94,4367,
US RUQ,4100275,CDM,972,RC,76705,HCPCS,OUTPATIENT,,,89,53.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,114.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,52.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.616,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2716.94,4368,
Report,4100277,CDM,972,RC,93925,HCPCS,OUTPATIENT,,,119,71.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,318.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,31.952,other,Not separately reimbursable,,31.95,,31.952,other,Not separately reimbursable,119,100,,,fee schedule,100% of CMS physician fee schedule,,,,243.2,other,Not separately reimbursable,,,,40,other,Not separately reimbursable,2717.94,4369,
US LE Arterial Duplex Bilateral,4100277,CDM,921,RC,93925,HCPCS,OUTPATIENT,,,612,367.2,26,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,215.12,35.15,,49.84,fee schedule,35.15% of LA custom fee schedule,195.53,31.95,,49.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,1.872,case rate,pays based on per visit rate,195.53,31.95,,62.4,Fee Schedule,31.95% of LA custom fee schedule,2718.94,4370,
Report,4100278,CDM,972,RC,93926,HCPCS,OUTPATIENT,,,76,45.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,168.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,49.84,other,Not separately reimbursable,,31.95,,49.84,other,Not separately reimbursable,76,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.08,other,Not separately reimbursable,,,,62.4,other,Not separately reimbursable,2719.94,4371,
Report,4100278,CDM,972,RC,93926,HCPCS,OUTPATIENT,,,76,45.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,168.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,49.84,other,Not separately reimbursable,,31.95,,49.84,other,Not separately reimbursable,76,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.08,other,Not separately reimbursable,,,,62.4,other,Not separately reimbursable,2720.94,4372,
Radiology Exam,4100278,CDM,921,RC,93926,HCPCS,OUTPATIENT,,,425,255,26,361.25,85,,289,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,61.344,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,61.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,7.6,case rate,pays based on per visit rate,135.79,31.95,,76.8,Fee Schedule,31.95% of LA custom fee schedule,2721.94,4373,
US LE Arterial Duplex Left,4100278,CDM,921,RC,93926,HCPCS,OUTPATIENT,,,425,255,26,361.25,85,,289,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,61.344,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,61.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,9.728,case rate,pays based on per visit rate,135.79,31.95,,76.8,Fee Schedule,31.95% of LA custom fee schedule,2722.94,4374,
US LE Arterial Duplex Right,4100278,CDM,921,RC,93926,HCPCS,OUTPATIENT,,,425,255,26,361.25,85,,289,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,17.936,case rate,pays based on per visit rate,135.79,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2723.94,4375,
US Bladder w/ Residual,4100279,CDM,402,RC,76857,HCPCS,OUTPATIENT,,,367,220.2,TC,311.95,85,,249.56,Percent of total billed charges,85% of total billed charges,184.33,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,184.33,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,129,35.15,,15.336,fee schedule,35.15% of LA custom fee schedule,117.26,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,181.488,case rate,pays based on per visit rate,117.26,31.95,,19.2,Fee Schedule,31.95% of LA custom fee schedule,2724.94,4376,
Report,4100279,CDM,972,RC,76857,HCPCS,OUTPATIENT,,,90,54,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,62.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.336,other,Not separately reimbursable,,31.95,,15.336,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,24.32,other,Not separately reimbursable,,,,19.2,other,Not separately reimbursable,2725.94,4377,
US Breast Biopsy Loc Plcmt Ea Addl,4100280,CDM,402,RC,19084,HCPCS,OUTPATIENT,,,327,196.2,TC,277.95,85,,222.36,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.48,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,104.48,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,265,100,,5.072,case rate,pays based on per visit rate,130.8,40,,19.2,percent of total billed charges,40% of total billed charges,2726.94,4378,
Report,4100280,CDM,972,RC,19084,HCPCS,OUTPATIENT,,,240,144,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,527.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,72.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.096,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2727.94,4379,
US Breast Biopsy Loc Plcmt 1st Les,4100281,CDM,402,RC,19083,HCPCS,OUTPATIENT,,,2106,1263.6,TC,1790.1,85,,1432.08,Percent of total billed charges,85% of total billed charges,1095.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1095.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,672.87,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,672.87,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,265,100,,4.256,case rate,pays based on per visit rate,842.4,40,,16,percent of total billed charges,40% of total billed charges,2728.94,4380,
Report,4100281,CDM,972,RC,19083,HCPCS,OUTPATIENT,,,525,315,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,664.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,145.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2729.94,4381,
Report,4100282,CDM,972,RC,76641,HCPCS,OUTPATIENT,,,111,66.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,135.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,60.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.912,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2730.94,4382,
US Breast Bilateral Complete Profee,4100282,CDM,972,RC,76641,HCPCS,OUTPATIENT,,,111,66.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,135.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,60.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2731.94,4383,
Report,4100283,CDM,972,RC,76642,HCPCS,OUTPATIENT,,,104,62.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,46.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.304,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2732.94,4384,
US Breast Bilateral Limited Profee,4100283,CDM,972,RC,76642,HCPCS,OUTPATIENT,,,104,62.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.784,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,46.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,203.328,other,Not separately reimbursable,,,,16,other,Not separately reimbursable,2733.94,4385,
US Breast Bilateral Complete,4100284,CDM,402,RC,76641,HCPCS,OUTPATIENT,,,285,171,1-TC|2-LT,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,17.896,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,17.896,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,244,case rate,pays based on per visit rate,91.06,31.95,,22.4,Fee Schedule,31.95% of LA custom fee schedule,2734.94,4386,
US Breast Left Complete,4100284,CDM,402,RC,76641,HCPCS,OUTPATIENT,,,285,171,1-TC|2-LT,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,17.896,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,17.896,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,1.2,case rate,pays based on per visit rate,91.06,31.95,,22.4,Fee Schedule,31.95% of LA custom fee schedule,2735.94,4387,
Report,4100284,CDM,972,RC,76641,HCPCS,OUTPATIENT,,,111,66.6,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,135.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,17.896,other,Not separately reimbursable,,31.95,,17.896,other,Not separately reimbursable,60.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,785.712,other,Not separately reimbursable,,,,22.4,other,Not separately reimbursable,2736.94,4388,
US Breast Bilateral Limited,4100285,CDM,402,RC,76642,HCPCS,OUTPATIENT,,,285,171,1-TC|2-LT,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,25.304,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,25.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,3.344,case rate,pays based on per visit rate,91.06,31.95,,31.68,Fee Schedule,31.95% of LA custom fee schedule,2737.94,4389,
US Breast Left Limited,4100285,CDM,402,RC,76642,HCPCS,OUTPATIENT,,,285,171,1-TC|2-LT,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,25.304,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,25.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,13.984,case rate,pays based on per visit rate,91.06,31.95,,31.68,Fee Schedule,31.95% of LA custom fee schedule,2738.94,4390,
Report,4100285,CDM,972,RC,76642,HCPCS,OUTPATIENT,,,104,62.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.304,other,Not separately reimbursable,,31.95,,25.304,other,Not separately reimbursable,46.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.816,other,Not separately reimbursable,,,,31.68,other,Not separately reimbursable,2739.94,4391,
US Breast Right Complete,4100286,CDM,402,RC,76641,HCPCS,OUTPATIENT,,,285,171,1-RT|2-TC,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,25.56,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,25.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,13.68,case rate,pays based on per visit rate,91.06,31.95,,32,Fee Schedule,31.95% of LA custom fee schedule,2740.94,4392,
Report,4100286,CDM,972,RC,76641,HCPCS,OUTPATIENT,,,111,66.6,1-RT|2-TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,135.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.56,other,Not separately reimbursable,,31.95,,25.56,other,Not separately reimbursable,60.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,36.784,other,Not separately reimbursable,,,,32,other,Not separately reimbursable,2741.94,4393,
FMC US Breast Right Complete,4100286,CDM,402,RC,76641,HCPCS,OUTPATIENT,,,285,171,1-RT|2-TC,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,25.56,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,25.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,177.84,case rate,pays based on per visit rate,91.06,31.95,,32,Fee Schedule,31.95% of LA custom fee schedule,2742.94,4394,
US Breast Right Limited,4100287,CDM,402,RC,76642,HCPCS,OUTPATIENT,,,285,171,1-RT|2-TC,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,25.56,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,25.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,120.656,case rate,pays based on per visit rate,91.06,31.95,,32,Fee Schedule,31.95% of LA custom fee schedule,2743.94,4395,
Report,4100287,CDM,972,RC,76642,HCPCS,OUTPATIENT,,,104,62.4,1-RT|2-TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.56,other,Not separately reimbursable,,31.95,,25.56,other,Not separately reimbursable,46.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,116.736,other,Not separately reimbursable,,,,32,other,Not separately reimbursable,2744.94,4396,
FMC US Breast Right Limited,4100287,CDM,402,RC,76642,HCPCS,OUTPATIENT,,,285,171,1-RT|2-TC,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,135.04,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,25.56,fee schedule,35.15% of LA custom fee schedule,91.06,31.95,,25.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,19.152,case rate,pays based on per visit rate,91.06,31.95,,32,Fee Schedule,31.95% of LA custom fee schedule,2745.94,4397,
Report,4100288,CDM,972,RC,93880,HCPCS,OUTPATIENT,,,118,70.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,251.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.56,other,Not separately reimbursable,,31.95,,25.56,other,Not separately reimbursable,118,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,32,other,Not separately reimbursable,2746.94,4398,
US Carotid Doppler Bilateral,4100288,CDM,921,RC,93880,HCPCS,OUTPATIENT,,,612,367.2,,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,215.12,35.15,,25.56,fee schedule,35.15% of LA custom fee schedule,195.53,31.95,,25.56,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,1.216,case rate,pays based on per visit rate,195.53,31.95,,32,Fee Schedule,31.95% of LA custom fee schedule,2747.94,4399,
Report,4100289,CDM,972,RC,76604,HCPCS,OUTPATIENT,,,82,49.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,95.848,other,Not separately reimbursable,,31.95,,95.848,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,120,other,Not separately reimbursable,2748.94,4400,
US Chest,4100289,CDM,402,RC,76604,HCPCS,OUTPATIENT,,,539,323.4,26,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,39.216,case rate,pays based on per visit rate,172.21,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2749.94,4401,
FMC MA CAD DIAGNOSTIC MAMMO,4100290,CDM,403,RC,77065,HCPCS,OUTPATIENT,,,38,22.8,TC,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.36,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,12.14,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,52.592,case rate,pays based on per visit rate,12.14,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2750.94,4402,
FMC MA Cad Diag Professional,4100290,CDM,972,RC,77065,HCPCS,OUTPATIENT,,,10,6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.504,other,Not separately reimbursable,,31.95,,11.504,other,Not separately reimbursable,10,100,,,fee schedule,100% of CMS physician fee schedule,,,,42.256,other,Not separately reimbursable,,,,14.4,other,Not separately reimbursable,2751.94,4403,
US Echo Color Flow Doppler,4100292,CDM,480,RC,93325,HCPCS,OUTPATIENT,,,325,195,TC,276.25,85,,221,Percent of total billed charges,85% of total billed charges,304.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,304.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,114.24,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,103.84,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,494,100,,42.864,case rate,pays based on per visit rate,103.84,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,2752.94,4404,
Report,4100292,CDM,972,RC,93325,HCPCS,OUTPATIENT,,,11,6.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,11,100,,,fee schedule,100% of CMS physician fee schedule,,,,75.24,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2753.94,4405,
Report,4100293,CDM,972,RC,93975,HCPCS,OUTPATIENT,,,171,102.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,348.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,171,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.104,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2754.94,4406,
US Art/Vein Abd/Pelvis/Scrotal Complete,4100293,CDM,921,RC,93975,HCPCS,OUTPATIENT,,,573,343.8,26,487.05,85,,389.64,Percent of total billed charges,85% of total billed charges,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,201.41,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,183.07,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,381.216,case rate,pays based on per visit rate,183.07,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2755.94,4407,
Report,4100294,CDM,972,RC,93976,HCPCS,OUTPATIENT,,,120,72,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,188.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.648,other,Not separately reimbursable,,31.95,,6.648,other,Not separately reimbursable,106.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.64,other,Not separately reimbursable,,,,8.32,other,Not separately reimbursable,2756.94,4408,
US Art/Vein Abd/Pelvis/Scrotal Limited,4100294,CDM,402,RC,93976,HCPCS,OUTPATIENT,,,764,458.4,26,649.4,85,,519.52,Percent of total billed charges,85% of total billed charges,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,268.55,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,244.1,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,9.032,case rate,pays based on per visit rate,244.1,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2757.94,4409,
Report,4100295,CDM,972,RC,93931,HCPCS,OUTPATIENT,,,75,45,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,75,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.024,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2758.94,4410,
US UE Arterial Duplex Right,4100295,CDM,921,RC,93931,HCPCS,OUTPATIENT,,,336,201.6,26,285.6,85,,228.48,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,118.1,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,107.35,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,3.648,case rate,pays based on per visit rate,107.35,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2759.94,4411,
Report,4100296,CDM,972,RC,93931,HCPCS,OUTPATIENT,,,75,45,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,75,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.6,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2760.94,4412,
US UE Arterial Duplex Left,4100296,CDM,921,RC,93931,HCPCS,OUTPATIENT,,,336,201.6,26,285.6,85,,228.48,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,118.1,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,107.35,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,4.256,case rate,pays based on per visit rate,107.35,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2761.94,4413,
Report,4100297,CDM,972,RC,93930,HCPCS,OUTPATIENT,,,119,71.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,257.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.008,other,Not separately reimbursable,,31.95,,23.008,other,Not separately reimbursable,119,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.728,other,Not separately reimbursable,,,,28.8,other,Not separately reimbursable,2762.94,4414,
US UE Arterial Duplex Bilateral,4100297,CDM,921,RC,93930,HCPCS,OUTPATIENT,,,764,458.4,26,649.4,85,,519.52,Percent of total billed charges,85% of total billed charges,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,268.55,35.15,,23.008,fee schedule,35.15% of LA custom fee schedule,244.1,31.95,,23.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,9.728,case rate,pays based on per visit rate,244.1,31.95,,28.8,Fee Schedule,31.95% of LA custom fee schedule,2763.94,4415,
US Echocardiogram Complete,4100298,CDM,480,RC,93306,HCPCS,OUTPATIENT,,,1300,780,TC,1105,85,,884,Percent of total billed charges,85% of total billed charges,1460.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1460.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,456.95,35.15,,13.032,fee schedule,35.15% of LA custom fee schedule,415.35,31.95,,13.032,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,494,100,,9.728,case rate,pays based on per visit rate,415.35,31.95,,16.32,Fee Schedule,31.95% of LA custom fee schedule,2764.94,4416,
Report,4100298,CDM,972,RC,93306,HCPCS,OUTPATIENT,,,188,112.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,348.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.032,other,Not separately reimbursable,,31.95,,13.032,other,Not separately reimbursable,113.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.728,other,Not separately reimbursable,,,,16.32,other,Not separately reimbursable,2765.94,4417,
US Extremity Nonvascular Ltd Anatomic Specific Left,4100299,CDM,402,RC,76882,HCPCS,OUTPATIENT,,,300,180,1-TC|2-LT,255,85,,204,Percent of total billed charges,85% of total billed charges,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,13.032,fee schedule,35.15% of LA custom fee schedule,95.85,31.95,,13.032,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,136.8,case rate,pays based on per visit rate,95.85,31.95,,16.32,Fee Schedule,31.95% of LA custom fee schedule,2766.94,4418,
Report,4100299,CDM,972,RC,76882,HCPCS,OUTPATIENT,,,74,44.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.736,other,Not separately reimbursable,,31.95,,10.736,other,Not separately reimbursable,27.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.872,other,Not separately reimbursable,,,,13.44,other,Not separately reimbursable,2767.94,4419,
US Extremity Nonvascular Ltd Anatomic Spec Bilat Profee,4100299,CDM,972,RC,76882,HCPCS,OUTPATIENT,,,74,44.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.736,other,Not separately reimbursable,,31.95,,10.736,other,Not separately reimbursable,27.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.808,other,Not separately reimbursable,,,,13.44,other,Not separately reimbursable,2768.94,4420,
US Extremity Nonvascular Ltd Anatomic Specific Lt,4100300,CDM,402,RC,76882,HCPCS,OUTPATIENT,,,300,180,1-TC|2-LT,255,85,,204,Percent of total billed charges,85% of total billed charges,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,10.736,fee schedule,35.15% of LA custom fee schedule,95.85,31.95,,10.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,12.768,case rate,pays based on per visit rate,95.85,31.95,,13.44,Fee Schedule,31.95% of LA custom fee schedule,2769.94,4421,
Report,4100300,CDM,972,RC,76882,HCPCS,OUTPATIENT,,,74,44.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.272,other,Not separately reimbursable,,31.95,,12.272,other,Not separately reimbursable,27.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.768,other,Not separately reimbursable,,,,15.36,other,Not separately reimbursable,2770.94,4422,
US Extremity Nonvascular Ltd Anatomic Specific Rt,4100301,CDM,402,RC,76882,HCPCS,OUTPATIENT,,,300,180,1-TC|2-RT,255,85,,204,Percent of total billed charges,85% of total billed charges,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,12.272,fee schedule,35.15% of LA custom fee schedule,95.85,31.95,,12.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,13.376,case rate,pays based on per visit rate,95.85,31.95,,15.36,Fee Schedule,31.95% of LA custom fee schedule,2771.94,4423,
Report,4100301,CDM,972,RC,76882,HCPCS,OUTPATIENT,,,74,44.4,1-TC|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,12.272,other,Not separately reimbursable,,31.95,,12.272,other,Not separately reimbursable,27.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,15.36,other,Not separately reimbursable,2772.94,4424,
FMC US Extremity Nonvascular Ltd Anatomci Spec Right,4100301,CDM,402,RC,76882,HCPCS,OUTPATIENT,,,300,180,1-TC|2-RT,255,85,,204,Percent of total billed charges,85% of total billed charges,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,12.272,fee schedule,35.15% of LA custom fee schedule,95.85,31.95,,12.272,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,2.736,case rate,pays based on per visit rate,95.85,31.95,,15.36,Fee Schedule,31.95% of LA custom fee schedule,2773.94,4425,
Report,4100302,CDM,972,RC,76881,HCPCS,OUTPATIENT,,,95,57,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,112.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,9.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2774.94,4426,
US Extremity Non-Vascular Bilateral Profee,4100302,CDM,972,RC,76881,HCPCS,OUTPATIENT,,,95,57,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,112.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,9.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,16.416,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2775.94,4427,
Report,4100303,CDM,972,RC,76881,HCPCS,OUTPATIENT,,,95,57,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,112.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,9.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,1003.2,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2776.94,4428,
US Extremity Non-Vascular Complete Bilateral,4100303,CDM,402,RC,76881,HCPCS,OUTPATIENT,,,539,323.4,1-26|2-LT,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,42.952,case rate,pays based on per visit rate,172.21,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2777.94,4429,
US Extremity Non-Vascular Complete Left,4100303,CDM,402,RC,76881,HCPCS,OUTPATIENT,,,539,323.4,1-26|2-LT,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,23.688,case rate,pays based on per visit rate,172.21,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2778.94,4430,
Report,4100304,CDM,972,RC,76881,HCPCS,OUTPATIENT,,,95,57,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,112.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.176,other,Not separately reimbursable,,31.95,,8.176,other,Not separately reimbursable,9.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,5016,other,Not separately reimbursable,,,,10.24,other,Not separately reimbursable,2779.94,4431,
US Extremity Non-Vascular Complete Right,4100304,CDM,402,RC,76881,HCPCS,OUTPATIENT,,,539,323.4,1-26|2-RT,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,5016,case rate,pays based on per visit rate,172.21,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2780.94,4432,
FMC US Extremity Non-Vascular Complete Right,4100304,CDM,402,RC,76881,HCPCS,OUTPATIENT,,,539,323.4,1-26|2-RT,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,5016,case rate,pays based on per visit rate,172.21,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2781.94,4433,
US Fetal Biophysical Profile,4100305,CDM,402,RC,76819,HCPCS,OUTPATIENT,,,538,322.8,TC,457.3,85,,365.84,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.11,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,171.89,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,5016,case rate,pays based on per visit rate,171.89,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2782.94,4434,
Report,4100305,CDM,972,RC,76819,HCPCS,OUTPATIENT,,,119,71.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,114.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,43.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,5016,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2783.94,4435,
Report,4100306,CDM,972,RC,75989,HCPCS,OUTPATIENT,,,178,106.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,155.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.504,other,Not separately reimbursable,,31.95,,11.504,other,Not separately reimbursable,50.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,711.36,other,Not separately reimbursable,,,,14.4,other,Not separately reimbursable,2784.94,4436,
Report,4100306,CDM,972,RC,75989,HCPCS,OUTPATIENT,,,178,106.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,155.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.648,other,Not separately reimbursable,,31.95,,6.648,other,Not separately reimbursable,50.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,851.2,other,Not separately reimbursable,,,,8.32,other,Not separately reimbursable,2785.94,4437,
CT Drainage - Abscess or Cyst,4100306,CDM,480,RC,75989,HCPCS,OUTPATIENT,,,468,280.8,26,397.8,85,,318.24,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,164.5,35.15,,31.952,fee schedule,35.15% of LA custom fee schedule,149.53,31.95,,31.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,494,100,,648.824,case rate,pays based on per visit rate,149.53,31.95,,40,Fee Schedule,31.95% of LA custom fee schedule,2786.94,4438,
US Drainage Abscess or Cyst,4100306,CDM,480,RC,75989,HCPCS,OUTPATIENT,,,468,280.8,26,397.8,85,,318.24,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,164.5,35.15,,31.952,fee schedule,35.15% of LA custom fee schedule,149.53,31.95,,31.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,494,100,,639.312,case rate,pays based on per visit rate,149.53,31.95,,40,Fee Schedule,31.95% of LA custom fee schedule,2787.94,4439,
XR Drainage Abscess or Cyst,4100306,CDM,480,RC,75989,HCPCS,OUTPATIENT,,,468,280.8,26,397.8,85,,318.24,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,164.5,35.15,,31.952,fee schedule,35.15% of LA custom fee schedule,149.53,31.95,,31.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,494,100,,73.552,case rate,pays based on per visit rate,149.53,31.95,,40,Fee Schedule,31.95% of LA custom fee schedule,2788.94,4440,
Report,4100306,CDM,972,RC,75989,HCPCS,OUTPATIENT,,,178,106.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,155.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,156.424,other,Not separately reimbursable,,31.95,,156.424,other,Not separately reimbursable,50.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,54.72,other,Not separately reimbursable,,,,195.84,other,Not separately reimbursable,2789.94,4441,
US Guide for CVA,4100307,CDM,402,RC,76937,HCPCS,OUTPATIENT,,,250,150,TC,212.5,85,,170,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,156.424,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,156.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,255.36,case rate,pays based on per visit rate,79.88,31.95,,195.84,Fee Schedule,31.95% of LA custom fee schedule,2790.94,4442,
Report,4100307,CDM,972,RC,76937,HCPCS,OUTPATIENT,,,45,27,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,156.424,other,Not separately reimbursable,,31.95,,156.424,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.944,other,Not separately reimbursable,,,,195.84,other,Not separately reimbursable,2791.94,4443,
US Guidance Needle Placement,4100308,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,400,240,TC,340,85,,272,Percent of total billed charges,85% of total billed charges,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,127.8,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,0.608,case rate,pays based on per visit rate,127.8,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2792.94,4444,
Report,4100308,CDM,972,RC,76942,HCPCS,OUTPATIENT,,,250,150,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,345.752,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2793.94,4445,
FMC US Guide Needle Placement,4100308,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,400,240,TC,340,85,,272,Percent of total billed charges,85% of total billed charges,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,127.8,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,10.576,case rate,pays based on per visit rate,127.8,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2794.94,4446,
FMC US Guide Needle Placement Profee,4100308,CDM,972,RC,76942,HCPCS,OUTPATIENT,,,250,150,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.176,other,Not separately reimbursable,,31.95,,8.176,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.576,other,Not separately reimbursable,,,,10.24,other,Not separately reimbursable,2795.94,4447,
Report,4100312,CDM,972,RC,76856,HCPCS,OUTPATIENT,,,102,61.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.176,other,Not separately reimbursable,,31.95,,8.176,other,Not separately reimbursable,64.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.4,other,Not separately reimbursable,,,,10.24,other,Not separately reimbursable,2796.94,4448,
US Pelvis Non-OB Complete,4100312,CDM,402,RC,76856,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,10.064,case rate,pays based on per visit rate,123.33,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2797.94,4449,
FMC US Pelvis,4100312,CDM,402,RC,76856,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,8.176,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,8.176,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,2.192,case rate,pays based on per visit rate,123.33,31.95,,10.24,Fee Schedule,31.95% of LA custom fee schedule,2798.94,4450,
FMC US Pelvis Profee,4100312,CDM,972,RC,76856,HCPCS,OUTPATIENT,,,102,61.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,24.28,other,Not separately reimbursable,,31.95,,24.28,other,Not separately reimbursable,64.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,74.6,other,Not separately reimbursable,,,,30.4,other,Not separately reimbursable,2799.94,4451,
Report,4100313,CDM,972,RC,76857,HCPCS,OUTPATIENT,,,96,57.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,62.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,24.28,other,Not separately reimbursable,,31.95,,24.28,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.544,other,Not separately reimbursable,,,,30.4,other,Not separately reimbursable,2800.94,4452,
US Pelvis Non-OB Limited,4100313,CDM,402,RC,76857,HCPCS,OUTPATIENT,,,367,220.2,26,311.95,85,,249.56,Percent of total billed charges,85% of total billed charges,184.33,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,184.33,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,129,35.15,,120.64,fee schedule,35.15% of LA custom fee schedule,117.26,31.95,,120.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,2.856,case rate,pays based on per visit rate,117.26,31.95,,151.04,Fee Schedule,31.95% of LA custom fee schedule,2801.94,4453,
US Biopsy Breast Left Addl Lesion,4100314,CDM,401,RC,19282,HCPCS,OUTPATIENT,,,214,128.4,1-TC|2-LT,181.9,85,,145.52,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.37,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,68.37,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,300,100,,14.072,case rate,pays based on per visit rate,85.6,40,,151.04,percent of total billed charges,40% of total billed charges,2802.94,4454,
Report,4100314,CDM,972,RC,19282,HCPCS,OUTPATIENT,,,107,64.2,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,17.896,other,Not separately reimbursable,,31.95,,17.896,other,Not separately reimbursable,46.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,103.36,other,Not separately reimbursable,,,,22.4,other,Not separately reimbursable,2803.94,4455,
US Biopsy Breast Right Addl Lesion,4100314,CDM,401,RC,19282,HCPCS,OUTPATIENT,,,214,128.4,1-TC|2-LT,181.9,85,,145.52,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,68.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,300,100,,129.168,case rate,pays based on per visit rate,85.6,40,,22.4,percent of total billed charges,40% of total billed charges,2804.94,4456,
Report,4100314,CDM,972,RC,19282,HCPCS,OUTPATIENT,,,107,64.2,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,17.896,other,Not separately reimbursable,,31.95,,17.896,other,Not separately reimbursable,46.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.344,other,Not separately reimbursable,,,,22.4,other,Not separately reimbursable,2805.94,4457,
US Pregnancy After 1st Trimester,4100316,CDM,402,RC,76805,HCPCS,OUTPATIENT,,,450,270,TC,382.5,85,,306,Percent of total billed charges,85% of total billed charges,243.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,243.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,17.896,fee schedule,35.15% of LA custom fee schedule,143.78,31.95,,17.896,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,3.8,case rate,pays based on per visit rate,143.78,31.95,,22.4,Fee Schedule,31.95% of LA custom fee schedule,2806.94,4458,
Report,4100316,CDM,972,RC,76805,HCPCS,OUTPATIENT,,,154,92.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,17.896,other,Not separately reimbursable,,31.95,,17.896,other,Not separately reimbursable,78.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.648,other,Not separately reimbursable,,,,22.4,other,Not separately reimbursable,2807.94,4459,
US Pregnancy Multi Gest > 14 weeks,4100317,CDM,402,RC,76805,HCPCS,OUTPATIENT,,,386,231.6,TC,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,243.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,243.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,3.8,case rate,pays based on per visit rate,123.33,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2808.94,4460,
Report,4100317,CDM,972,RC,76805,HCPCS,OUTPATIENT,,,153,91.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,78.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,145.856,other,Not separately reimbursable,,,,20.8,other,Not separately reimbursable,2809.94,4461,
FMC US Pregnancy Multi Gest > 14 Weeks,4100317,CDM,402,RC,76810,HCPCS,OUTPATIENT,,,386,231.6,TC,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,16.616,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,145.856,case rate,pays based on per visit rate,123.33,31.95,,20.8,Fee Schedule,31.95% of LA custom fee schedule,2810.94,4462,
FMC US Pregnancy Multi Gest > 14 Weeks Profee,4100317,CDM,972,RC,76810,HCPCS,OUTPATIENT,,,153,91.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,19.168,other,Not separately reimbursable,,31.95,,19.168,other,Not separately reimbursable,36.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,163.064,other,Not separately reimbursable,,,,24,other,Not separately reimbursable,2811.94,4463,
US Pregnancy 1st Trimester,4100318,CDM,402,RC,76801,HCPCS,OUTPATIENT,,,475,285,TC,403.75,85,,323,Percent of total billed charges,85% of total billed charges,243.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,243.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,166.96,35.15,,19.168,fee schedule,35.15% of LA custom fee schedule,151.76,31.95,,19.168,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,37.424,case rate,pays based on per visit rate,151.76,31.95,,24,Fee Schedule,31.95% of LA custom fee schedule,2812.94,4464,
Report,4100318,CDM,972,RC,76801,HCPCS,OUTPATIENT,,,154,92.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,155.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,21.728,other,Not separately reimbursable,,31.95,,21.728,other,Not separately reimbursable,62.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.32,other,Not separately reimbursable,,,,27.2,other,Not separately reimbursable,2813.94,4465,
Report,4100319,CDM,972,RC,76815,HCPCS,OUTPATIENT,,,100,60,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,21.728,other,Not separately reimbursable,,31.95,,21.728,other,Not separately reimbursable,44.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.944,other,Not separately reimbursable,,,,27.2,other,Not separately reimbursable,2814.94,4466,
US Pregnancy Limited,4100319,CDM,402,RC,76815,HCPCS,OUTPATIENT,,,539,323.4,26,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,164.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,164.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,38.344,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,38.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,3.16,case rate,pays based on per visit rate,172.21,31.95,,48,Fee Schedule,31.95% of LA custom fee schedule,2815.94,4467,
Report,4100320,CDM,972,RC,76817,HCPCS,OUTPATIENT,,,116,69.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,122.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,38.344,other,Not separately reimbursable,,31.95,,38.344,other,Not separately reimbursable,50.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,21.672,other,Not separately reimbursable,,,,48,other,Not separately reimbursable,2816.94,4468,
US Pregnancy Transvaginal,4100320,CDM,402,RC,76817,HCPCS,OUTPATIENT,,,539,323.4,26,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,3.656,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,1486.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,21.672,case rate,pays based on per visit rate,172.21,31.95,,3.32,Fee Schedule,31.95% of LA custom fee schedule,2817.94,4469,
US Renal Doppler,4100321,CDM,921,RC,93978,HCPCS,OUTPATIENT,,,525,315,TC,446.25,85,,357,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,184.54,35.15,,14.064,fee schedule,35.15% of LA custom fee schedule,167.74,31.95,,1.288,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,6.504,case rate,pays based on per visit rate,167.74,31.95,,12.784,Fee Schedule,31.95% of LA custom fee schedule,2818.94,4470,
Report,4100321,CDM,972,RC,93978,HCPCS,OUTPATIENT,,,118,70.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,236.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.28,other,Not separately reimbursable,,31.95,,12.784,other,Not separately reimbursable,118,100,,,fee schedule,100% of CMS physician fee schedule,,,,48.032,other,Not separately reimbursable,,,,16.616,other,Not separately reimbursable,2819.94,4471,
Report,4100322,CDM,972,RC,76775,HCPCS,OUTPATIENT,,,85,51,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,9.36,other,Not separately reimbursable,,31.95,,127.8,other,Not separately reimbursable,28.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,22.68,other,Not separately reimbursable,,,,8.512,other,Not separately reimbursable,2820.94,4472,
US Retroperitoneal Limited,4100322,CDM,402,RC,76775,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,26.432,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,177.752,case rate,pays based on per visit rate,123.33,31.95,,24.024,Fee Schedule,31.95% of LA custom fee schedule,2821.94,4473,
Report,4100323,CDM,972,RC,76770,HCPCS,OUTPATIENT,,,109,65.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,142.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,97.016,other,Not separately reimbursable,,31.95,,127.8,other,Not separately reimbursable,64.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.416,other,Not separately reimbursable,,,,88.184,other,Not separately reimbursable,2822.94,4474,
US Retroperitoneal Complete,4100323,CDM,402,RC,76770,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,83.8,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,10.576,case rate,pays based on per visit rate,123.33,31.95,,76.168,Fee Schedule,31.95% of LA custom fee schedule,2823.94,4475,
Report,4100326,CDM,972,RC,76870,HCPCS,OUTPATIENT,,,94,56.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,132.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,127.8,other,Not separately reimbursable,61.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.912,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2824.94,4476,
US Scrotum (Contents),4100326,CDM,402,RC,76870,HCPCS,OUTPATIENT,,,538,322.8,26,457.3,85,,365.84,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.11,35.15,,134.136,fee schedule,35.15% of LA custom fee schedule,171.89,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,145.856,case rate,pays based on per visit rate,171.89,31.95,,121.92,Fee Schedule,31.95% of LA custom fee schedule,2825.94,4477,
Report,4100327,CDM,972,RC,76536,HCPCS,OUTPATIENT,,,83,49.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,143.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,120.632,other,Not separately reimbursable,,31.95,,127.8,other,Not separately reimbursable,73.91,100,,,fee schedule,100% of CMS physician fee schedule,,,,129.168,other,Not separately reimbursable,,,,109.656,other,Not separately reimbursable,2826.94,4478,
US Head/Neck Soft Tissue,4100327,CDM,402,RC,76536,HCPCS,OUTPATIENT,,,538,322.8,26,457.3,85,,365.84,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.11,35.15,,134.136,fee schedule,35.15% of LA custom fee schedule,171.89,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,204.776,case rate,pays based on per visit rate,171.89,31.95,,121.92,Fee Schedule,31.95% of LA custom fee schedule,2827.94,4479,
Report,4100328,CDM,972,RC,76776,HCPCS,OUTPATIENT,,,114,68.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,193.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,134.136,other,Not separately reimbursable,,31.95,,127.8,other,Not separately reimbursable,98.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.08,other,Not separately reimbursable,,,,121.92,other,Not separately reimbursable,2828.94,4480,
Report,4100328,CDM,972,RC,76776,HCPCS,OUTPATIENT,,,114,68.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,193.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,120.632,other,Not separately reimbursable,,31.95,,127.8,other,Not separately reimbursable,98.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,109.656,other,Not separately reimbursable,2829.94,4481,
US Kidney Transplant Left,4100328,CDM,402,RC,76776,HCPCS,OUTPATIENT,,,450,270,26,382.5,85,,306,Percent of total billed charges,85% of total billed charges,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,143.78,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,95.832,case rate,pays based on per visit rate,143.78,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2830.94,4482,
US Kidney Transplant Right,4100328,CDM,402,RC,76776,HCPCS,OUTPATIENT,,,450,270,26,382.5,85,,306,Percent of total billed charges,85% of total billed charges,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,228.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,143.78,31.95,,132.656,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,31.312,case rate,pays based on per visit rate,143.78,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2831.94,4483,
US Transrectal,4100329,CDM,402,RC,76872,HCPCS,OUTPATIENT,,,539,323.4,TC,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,232.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,232.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,132.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,4.712,case rate,pays based on per visit rate,172.21,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2832.94,4484,
Report,4100329,CDM,972,RC,76872,HCPCS,OUTPATIENT,,,100,60,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,135.472,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.92,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2833.94,4485,
US Transrectal,4100329,CDM,402,RC,76872,HCPCS,OUTPATIENT,,,539,323.4,TC,458.15,85,,366.52,Percent of total billed charges,85% of total billed charges,232.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,232.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,172.21,31.95,,135.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,96.472,case rate,pays based on per visit rate,172.21,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2834.94,4486,
US Transrectal Report BCE,4100329,CDM,972,RC,76872,HCPCS,OUTPATIENT,,,100,60,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,135.472,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,31.312,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2835.94,4487,
Report,4100330,CDM,972,RC,76830,HCPCS,OUTPATIENT,,,106,63.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,137.768,other,Not separately reimbursable,76.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,319.2,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2836.94,4488,
US Transvaginal,4100330,CDM,402,RC,76830,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,13.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,319.2,case rate,pays based on per visit rate,123.33,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2837.94,4489,
US Transvaginal,4100330,CDM,402,RC,76830,HCPCS,OUTPATIENT,,,386,231.6,26,328.1,85,,262.48,Percent of total billed charges,85% of total billed charges,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,216.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,123.33,31.95,,139.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,443.84,case rate,pays based on per visit rate,123.33,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2838.94,4490,
Report,4100330,CDM,972,RC,76830,HCPCS,OUTPATIENT,,,106,63.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,48.928,other,Not separately reimbursable,,31.95,,139.56,other,Not separately reimbursable,76.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,39.52,other,Not separately reimbursable,,,,44.472,other,Not separately reimbursable,2839.94,4491,
US UE Art Duplex Ltd,4100331,CDM,921,RC,93931,HCPCS,OUTPATIENT,,,336,201.6,TC,285.6,85,,228.48,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,118.1,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,107.35,31.95,,14.056,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,39.52,case rate,pays based on per visit rate,107.35,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2840.94,4492,
Report,4100331,CDM,972,RC,93931,HCPCS,OUTPATIENT,,,75,45,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,64.68,other,Not separately reimbursable,,31.95,,14.184,other,Not separately reimbursable,75,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,58.792,other,Not separately reimbursable,2841.94,4493,
US ABI's,4100332,CDM,402,RC,93922,HCPCS,OUTPATIENT,,,225,135,TC,191.25,85,,153,Percent of total billed charges,85% of total billed charges,322.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,322.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.09,35.15,,78.456,fee schedule,35.15% of LA custom fee schedule,71.89,31.95,,14.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,12.4,case rate,pays based on per visit rate,71.89,31.95,,71.312,Fee Schedule,31.95% of LA custom fee schedule,2842.94,4494,
Report,4100332,CDM,972,RC,93922,HCPCS,OUTPATIENT,,,40,24,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,14.184,other,Not separately reimbursable,40,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.296,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2843.94,4495,
Report,4100334,CDM,972,RC,93970,HCPCS,OUTPATIENT,,,105,63,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,243.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,14.184,other,Not separately reimbursable,105,100,,,fee schedule,100% of CMS physician fee schedule,,,,304,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2844.94,4496,
US UE Venous Duplex Bilateral,4100334,CDM,921,RC,93970,HCPCS,OUTPATIENT,,,612,367.2,26,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,215.12,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,195.53,31.95,,14.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,13.984,case rate,pays based on per visit rate,195.53,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2845.94,4497,
Report,4100335,CDM,972,RC,93971,HCPCS,OUTPATIENT,,,68,40.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,14.184,other,Not separately reimbursable,68,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.968,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2846.94,4498,
US UE Venous Duplex Right,4100335,CDM,921,RC,93971,HCPCS,OUTPATIENT,,,425,255,26,361.25,85,,289,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,65.24,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,14.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,8.208,case rate,pays based on per visit rate,135.79,31.95,,59.296,Fee Schedule,31.95% of LA custom fee schedule,2847.94,4499,
Report,4100336,CDM,972,RC,93971,HCPCS,OUTPATIENT,,,68,40.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,141.344,other,Not separately reimbursable,68,100,,,fee schedule,100% of CMS physician fee schedule,,,,1083.76,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2848.94,4500,
US UE Venous Duplex Left,4100336,CDM,921,RC,93971,HCPCS,OUTPATIENT,,,425,255,1-26|2-LT,361.25,85,,289,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,142.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,706.8,case rate,pays based on per visit rate,135.79,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2849.94,4501,
Report,4100337,CDM,972,RC,74021,HCPCS,OUTPATIENT,,,40,24,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,142.432,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.024,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2850.94,4502,
XR Abdomen 3 or More Views,4100337,CDM,320,RC,74021,HCPCS,OUTPATIENT,,,270,162,26,229.5,85,,183.6,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,94.91,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,86.27,31.95,,142.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,12.4,case rate,pays based on per visit rate,86.27,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2851.94,4503,
XR Abdomen Series w/ Chest1 View,4100338,CDM,320,RC,74022,HCPCS,OUTPATIENT,,,364,218.4,TC,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,142.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.376,case rate,pays based on per visit rate,116.3,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2852.94,4504,
Report,4100338,CDM,972,RC,74022,HCPCS,OUTPATIENT,,,49,29.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,58.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,142.432,other,Not separately reimbursable,30.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.872,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2853.94,4505,
Report,4100339,CDM,972,RC,74019,HCPCS,OUTPATIENT,,,35,21,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,83.8,other,Not separately reimbursable,,31.95,,143.136,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,76.168,other,Not separately reimbursable,2854.94,4506,
XR Abdomen 2 Views,4100339,CDM,320,RC,74019,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,83.8,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,143.136,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,4.56,case rate,pays based on per visit rate,73.49,31.95,,76.168,Fee Schedule,31.95% of LA custom fee schedule,2855.94,4507,
XR Abdomen Single View (KUB),4100340,CDM,320,RC,74018,HCPCS,OUTPATIENT,,,230,138,TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,120.632,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,143.136,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,255.968,case rate,pays based on per visit rate,73.49,31.95,,109.656,Fee Schedule,31.95% of LA custom fee schedule,2856.94,4508,
Report,4100340,CDM,972,RC,74018,HCPCS,OUTPATIENT,,,28,16.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,120.632,other,Not separately reimbursable,,31.95,,14.568,other,Not separately reimbursable,19.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,224.96,other,Not separately reimbursable,,,,109.656,other,Not separately reimbursable,2857.94,4509,
XR AC Joints w/ + w/o weights Bilateral,4100341,CDM,320,RC,73050,HCPCS,OUTPATIENT,,,230,138,1-50|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,83.8,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,14.568,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,224.96,case rate,pays based on per visit rate,73.49,31.95,,76.168,Fee Schedule,31.95% of LA custom fee schedule,2858.94,4510,
Report,4100341,CDM,972,RC,73050,HCPCS,OUTPATIENT,,,33,19.8,1-50|2-TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,120.632,other,Not separately reimbursable,,31.95,,14.568,other,Not separately reimbursable,17.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,218.88,other,Not separately reimbursable,,,,109.656,other,Not separately reimbursable,2859.94,4511,
Report,4100342,CDM,972,RC,74280,HCPCS,OUTPATIENT,,,150,90,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,283.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,120.632,other,Not separately reimbursable,,31.95,,150.808,other,Not separately reimbursable,141.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,32.832,other,Not separately reimbursable,,,,109.656,other,Not separately reimbursable,2860.94,4512,
XR Barium Enema w/ Air Complete,4100342,CDM,320,RC,74280,HCPCS,OUTPATIENT,,,425,255,26,361.25,85,,289,Percent of total billed charges,85% of total billed charges,312.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,312.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,111.64,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,151.568,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,207.936,case rate,pays based on per visit rate,135.79,31.95,,101.472,Fee Schedule,31.95% of LA custom fee schedule,2861.94,4513,
Report,4100343,CDM,972,RC,73600,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,83.8,other,Not separately reimbursable,,31.95,,151.824,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,60.8,other,Not separately reimbursable,,,,76.168,other,Not separately reimbursable,2862.94,4514,
XR Ankle 2 Views Bilateral Profee,4100343,CDM,972,RC,73600,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,89.984,other,Not separately reimbursable,,31.95,,151.824,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,72.96,other,Not separately reimbursable,,,,81.792,other,Not separately reimbursable,2863.94,4515,
Report,4100344,CDM,972,RC,73600,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,83.8,other,Not separately reimbursable,,31.95,,1768.24,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.672,other,Not separately reimbursable,,,,76.168,other,Not separately reimbursable,2864.94,4516,
XR Ankle 2 Views Bilateral,4100344,CDM,320,RC,73600,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.128,case rate,pays based on per visit rate,73.49,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2865.94,4517,
XR Ankle 2 Views Left,4100344,CDM,320,RC,73600,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,15.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,9.12,case rate,pays based on per visit rate,73.49,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2866.94,4518,
Report,4100345,CDM,972,RC,73600,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,153.36,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2867.94,4519,
XR Ankle 2 Views Right,4100345,CDM,320,RC,73600,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,153.36,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,19.76,case rate,pays based on per visit rate,73.49,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2868.94,4520,
FMC XR Ankle 2 Views Right,4100345,CDM,320,RC,73600,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,11.856,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,153.36,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,10.032,case rate,pays based on per visit rate,73.49,31.95,,10.776,Fee Schedule,31.95% of LA custom fee schedule,2869.94,4521,
Report,4100346,CDM,972,RC,73610,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,153.36,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2870.94,4522,
XR Ankle Complete Bilateral Profee,4100346,CDM,972,RC,73610,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,153.36,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2871.94,4523,
Report,4100347,CDM,972,RC,73610,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.856,other,Not separately reimbursable,,31.95,,154.64,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.032,other,Not separately reimbursable,,,,10.776,other,Not separately reimbursable,2872.94,4524,
XR Ankle Complete Left,4100347,CDM,320,RC,73610,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,48.928,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,159.752,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,10.032,case rate,pays based on per visit rate,73.49,31.95,,44.472,Fee Schedule,31.95% of LA custom fee schedule,2873.94,4525,
XR Ankle Complete Left,4100347,CDM,320,RC,73610,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,160.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,10.032,case rate,pays based on per visit rate,73.49,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2874.94,4526,
XR Ankle Complete Bilateral,4100347,CDM,320,RC,73610,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,64.68,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,163.584,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,28.576,case rate,pays based on per visit rate,73.49,31.95,,58.792,Fee Schedule,31.95% of LA custom fee schedule,2875.94,4527,
XR Ankle Complete Right,4100348,CDM,320,RC,73610,HCPCS,OUTPATIENT,,,230,138,1-RT|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,89.704,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,28.576,case rate,pays based on per visit rate,73.49,31.95,,81.536,Fee Schedule,31.95% of LA custom fee schedule,2876.94,4528,
Report,4100348,CDM,972,RC,73610,HCPCS,OUTPATIENT,,,28,16.8,1-RT|2-TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,73.952,other,Not separately reimbursable,,31.95,,16.616,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,28.576,other,Not separately reimbursable,,,,67.224,other,Not separately reimbursable,2877.94,4529,
XR Ankle Complete Right,4100348,CDM,320,RC,73610,HCPCS,OUTPATIENT,,,230,138,1-RT|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,64.68,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,28.576,case rate,pays based on per visit rate,73.49,31.95,,58.792,Fee Schedule,31.95% of LA custom fee schedule,2878.94,4530,
XR Ankle Complete Right,4100348,CDM,320,RC,73610,HCPCS,OUTPATIENT,,,230,138,1-RT|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,48.928,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,16.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.736,case rate,pays based on per visit rate,73.49,31.95,,44.472,Fee Schedule,31.95% of LA custom fee schedule,2879.94,4531,
FMC XR Ankle Complete Right,4100348,CDM,320,RC,73610,HCPCS,OUTPATIENT,,,230,138,1-RT|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,73.112,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,16.872,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.648,case rate,pays based on per visit rate,73.49,31.95,,66.456,Fee Schedule,31.95% of LA custom fee schedule,2880.94,4532,
Report,4100349,CDM,972,RC,73040,HCPCS,OUTPATIENT,,,82,49.2,1-26|2-50,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,64.68,other,Not separately reimbursable,,31.95,,17.384,other,Not separately reimbursable,82,100,,,fee schedule,100% of CMS physician fee schedule,,,,28.576,other,Not separately reimbursable,,,,58.792,other,Not separately reimbursable,2881.94,4533,
XR Arthrogram Shoulder Bilateral Profee,4100349,CDM,972,RC,73040,HCPCS,OUTPATIENT,,,82,49.2,1-26|2-50,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,73.952,other,Not separately reimbursable,,31.95,,17.384,other,Not separately reimbursable,82,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.648,other,Not separately reimbursable,,,,67.224,other,Not separately reimbursable,2882.94,4534,
Report,4100350,CDM,972,RC,73040,HCPCS,OUTPATIENT,,,112,67.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,17.64,other,Not separately reimbursable,92.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,28.576,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2883.94,4535,
XR Arthrogram Shoulder Left,4100350,CDM,320,RC,73040,HCPCS,OUTPATIENT,,,1357,814.2,26,1153.45,85,,922.76,Percent of total billed charges,85% of total billed charges,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.99,35.15,,48.928,fee schedule,35.15% of LA custom fee schedule,433.56,31.95,,17.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,8.208,case rate,pays based on per visit rate,433.56,31.95,,44.472,Fee Schedule,31.95% of LA custom fee schedule,2884.94,4536,
XR Arthrogram Shoulder Bilateral,4100350,CDM,320,RC,73040,HCPCS,OUTPATIENT,,,1357,814.2,26,1153.45,85,,922.76,Percent of total billed charges,85% of total billed charges,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.99,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,433.56,31.95,,17.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,28.576,case rate,pays based on per visit rate,433.56,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2885.94,4537,
Report,4100351,CDM,972,RC,73040,HCPCS,OUTPATIENT,,,112,67.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,17.64,other,Not separately reimbursable,92.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.104,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2886.94,4538,
XR Arthrogram Shoulder Right,4100351,CDM,320,RC,73040,HCPCS,OUTPATIENT,,,1357,814.2,26,1153.45,85,,922.76,Percent of total billed charges,85% of total billed charges,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.99,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,433.56,31.95,,17.64,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,27.36,case rate,pays based on per visit rate,433.56,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2887.94,4539,
FMC XR Arthrogram Shoulder Right,4100351,CDM,320,RC,73040,HCPCS,OUTPATIENT,,,1357,814.2,26,1153.45,85,,922.76,Percent of total billed charges,85% of total billed charges,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.99,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,433.56,31.95,,176.368,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.688,case rate,pays based on per visit rate,433.56,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2888.94,4540,
Report,4100352,CDM,972,RC,74270,HCPCS,OUTPATIENT,,,104,62.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,67.208,other,Not separately reimbursable,,31.95,,176.368,other,Not separately reimbursable,92.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,27.36,other,Not separately reimbursable,,,,61.088,other,Not separately reimbursable,2889.94,4541,
XR Barium Enema Complete,4100352,CDM,320,RC,74270,HCPCS,OUTPATIENT,,,605,363,26,514.25,85,,411.4,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,212.66,35.15,,6.92,fee schedule,35.15% of LA custom fee schedule,193.3,31.95,,178.92,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.472,case rate,pays based on per visit rate,193.3,31.95,,6.288,Fee Schedule,31.95% of LA custom fee schedule,2890.94,4542,
Report,4100354,CDM,972,RC,71045,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,31.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,6.92,other,Not separately reimbursable,,31.95,,178.92,other,Not separately reimbursable,15.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,27.36,other,Not separately reimbursable,,,,6.288,other,Not separately reimbursable,2891.94,4543,
XR Chest 1 View,4100354,CDM,320,RC,71045,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.496,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2892.94,4544,
XR Chest 1 View,4100354,CDM,320,RC,71045,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,93.36,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,27.36,case rate,pays based on per visit rate,73.49,31.95,,84.856,Fee Schedule,31.95% of LA custom fee schedule,2893.94,4545,
Report,4100355,CDM,972,RC,71046,HCPCS,OUTPATIENT,,,33,19.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.36,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,20.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,84.856,other,Not separately reimbursable,2894.94,4546,
XR Chest 2 Views,4100355,CDM,320,RC,71046,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.168,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2895.94,4547,
XR Chest 2 Views,4100355,CDM,320,RC,71046,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,27.36,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2896.94,4548,
Report,4100357,CDM,972,RC,71047,HCPCS,OUTPATIENT,,,41,24.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,25.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2897.94,4549,
XR Chest 3 Views,4100357,CDM,320,RC,71047,HCPCS,OUTPATIENT,,,200,120,26,170,85,,136,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,63.9,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,27.36,case rate,pays based on per visit rate,63.9,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2898.94,4550,
XR Chest 3 view,4100357,CDM,320,RC,71047,HCPCS,OUTPATIENT,,,200,120,26,170,85,,136,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,63.9,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.648,case rate,pays based on per visit rate,63.9,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2899.94,4551,
Report,4100357,CDM,972,RC,71047,HCPCS,OUTPATIENT,,,41,24.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,25.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.352,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2900.94,4552,
Report,4100358,CDM,972,RC,71048,HCPCS,OUTPATIENT,,,49,29.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,27.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.648,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2901.94,4553,
XR Chest 4 Views,4100358,CDM,320,RC,71048,HCPCS,OUTPATIENT,,,225,135,26,191.25,85,,153,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.09,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,71.89,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,34.352,case rate,pays based on per visit rate,71.89,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2902.94,4554,
XR Chest 4 or more views,4100358,CDM,972,RC,71048,HCPCS,OUTPATIENT,,,225,135,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,27.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.208,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2903.94,4555,
Report,4100358,CDM,972,RC,71048,HCPCS,OUTPATIENT,,,49,29.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,27.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.352,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2904.94,4556,
Report,4100359,CDM,972,RC,73000,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2905.94,4557,
XR Clavicle Bilateral Profee,4100359,CDM,972,RC,73000,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.352,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2906.94,4558,
Report,4100360,CDM,972,RC,73000,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.496,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2907.94,4559,
XR Clavicle Left,4100360,CDM,320,RC,73000,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,34.352,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2908.94,4560,
XR Clavicle Left,4100360,CDM,320,RC,73000,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.888,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2909.94,4561,
XR Clavicle Bilateral,4100360,CDM,320,RC,73000,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,34.352,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2910.94,4562,
Report,4100361,CDM,972,RC,73000,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2911.94,4563,
XR Clavicle Right,4100361,CDM,320,RC,73000,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,34.352,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2912.94,4564,
XR Clavicle Right,4100361,CDM,320,RC,73000,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.888,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2913.94,4565,
FMC XR Clavicle Right,4100361,CDM,320,RC,73000,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.888,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2914.94,4566,
Report,4100362,CDM,972,RC,74430,HCPCS,OUTPATIENT,,,48,28.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.168,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2915.94,4567,
XR Cystography,4100362,CDM,320,RC,74430,HCPCS,OUTPATIENT,,,1031,618.6,26,876.35,85,,701.08,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.4,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,329.4,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.496,case rate,pays based on per visit rate,329.4,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2916.94,4568,
Report,4100363,CDM,972,RC,73070,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.496,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2917.94,4569,
XR Elbow 2 Views Bilateral Profee,4100363,CDM,972,RC,73070,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,71.424,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.624,other,Not separately reimbursable,,,,64.92,other,Not separately reimbursable,2918.94,4570,
Report,4100364,CDM,972,RC,73070,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,71.424,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,64.92,other,Not separately reimbursable,2919.94,4571,
XR Elbow 2 Views Left,4100364,CDM,320,RC,73070,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,71.424,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.192,case rate,pays based on per visit rate,73.49,31.95,,64.92,Fee Schedule,31.95% of LA custom fee schedule,2920.94,4572,
XR Elbow 2 Views Left,4100364,CDM,320,RC,73070,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.776,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2921.94,4573,
XR Elbow 2 Views Bilateral,4100364,CDM,320,RC,73070,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,4.712,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2922.94,4574,
Report,4100365,CDM,972,RC,73070,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,18.4,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.776,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2923.94,4575,
XR Elbow 2 Views Right,4100365,CDM,320,RC,73070,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.384,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2924.94,4576,
XR Elbow 2 Views Right,4100365,CDM,320,RC,73070,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,18.632,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.384,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2925.94,4577,
FMC XR Elbow 2 Views Right,4100365,CDM,320,RC,73070,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,188.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.736,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2926.94,4578,
Report,4100366,CDM,972,RC,73080,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,189.144,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.496,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2927.94,4579,
XR Elbow Complete Bilateral Profee,4100366,CDM,972,RC,73080,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,189.144,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.496,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2928.94,4580,
Report,4100367,CDM,972,RC,73080,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,190.168,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.168,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2929.94,4581,
XR Elbow Complete Bilateral,4100367,CDM,320,RC,73080,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,190.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.128,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2930.94,4582,
XR Elbow Complete Left,4100367,CDM,320,RC,73080,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,191.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.624,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2931.94,4583,
Report,4100368,CDM,972,RC,73080,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,192.208,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.016,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2932.94,4584,
XR Elbow Complete Right,4100368,CDM,320,RC,73080,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,202.432,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.168,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2933.94,4585,
FMC XR Elbow Complete Right,4100368,CDM,320,RC,73080,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,203.712,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.624,case rate,pays based on per visit rate,73.49,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2934.94,4586,
XR Esophagus,4100369,CDM,320,RC,74220,HCPCS,OUTPATIENT,,,408,244.8,TC,346.8,85,,277.44,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,143.41,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,130.36,31.95,,203.712,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,8.208,case rate,pays based on per visit rate,130.36,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2935.94,4587,
Report,4100369,CDM,972,RC,74220,HCPCS,OUTPATIENT,,,70,42,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,122.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,203.712,other,Not separately reimbursable,61.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.992,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2936.94,4588,
XR Radiological Specimen,4100370,CDM,320,RC,76098,HCPCS,OUTPATIENT,,,1349,809.4,TC,1146.65,85,,917.32,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,474.17,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,431.01,31.95,,203.712,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.736,case rate,pays based on per visit rate,431.01,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2937.94,4589,
Report,4100370,CDM,972,RC,76098,HCPCS,OUTPATIENT,,,25,15,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,203.712,other,Not separately reimbursable,24.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2938.94,4590,
Report,4100371,CDM,972,RC,76080,HCPCS,OUTPATIENT,,,79,47.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,20.448,other,Not separately reimbursable,31.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.016,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2939.94,4591,
XR Fistula or Sinus Tract Abscess Study,4100371,CDM,320,RC,76080,HCPCS,OUTPATIENT,,,1272,763.2,26,1081.2,85,,864.96,Percent of total billed charges,85% of total billed charges,230.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,230.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.11,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,406.4,31.95,,20.448,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.536,case rate,pays based on per visit rate,406.4,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2940.94,4592,
Report,4100372,CDM,972,RC,70150,HCPCS,OUTPATIENT,,,40,24,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,20.448,other,Not separately reimbursable,30.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.344,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2941.94,4593,
XR Facial Bones Minimum 3 Views,4100372,CDM,320,RC,70150,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,20.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.32,case rate,pays based on per visit rate,116.3,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2942.94,4594,
XR Facial Bones Minimum 3 Views,4100372,CDM,320,RC,70150,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,7.168,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,20.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.04,case rate,pays based on per visit rate,116.3,31.95,,6.52,Fee Schedule,31.95% of LA custom fee schedule,2943.94,4595,
Report,4100373,CDM,972,RC,70140,HCPCS,OUTPATIENT,,,32,19.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.36,other,Not separately reimbursable,,31.95,,207.8,other,Not separately reimbursable,19.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.472,other,Not separately reimbursable,,,,84.856,other,Not separately reimbursable,2944.94,4596,
XR Facial Bones < 3 Views,4100373,CDM,320,RC,70140,HCPCS,OUTPATIENT,,,175,105,26,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,124.568,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,208.824,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.32,case rate,pays based on per visit rate,55.91,31.95,,113.232,Fee Schedule,31.95% of LA custom fee schedule,2945.94,4597,
XR Facial Bones < 3 Views,4100373,CDM,320,RC,70140,HCPCS,OUTPATIENT,,,175,105,26,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,124.568,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,21.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.472,case rate,pays based on per visit rate,55.91,31.95,,113.232,Fee Schedule,31.95% of LA custom fee schedule,2946.94,4598,
Report,4100373,CDM,972,RC,70140,HCPCS,OUTPATIENT,,,32,19.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,124.568,other,Not separately reimbursable,,31.95,,217.264,other,Not separately reimbursable,19.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.016,other,Not separately reimbursable,,,,113.232,other,Not separately reimbursable,2947.94,4599,
Report,4100374,CDM,972,RC,73552,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,153.256,other,Not separately reimbursable,,31.95,,218.536,other,Not separately reimbursable,23.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.432,other,Not separately reimbursable,,,,139.304,other,Not separately reimbursable,2948.94,4600,
XR Femur 2 Views Bilateral Profee,4100374,CDM,972,RC,73552,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,127.664,other,Not separately reimbursable,,31.95,,219.048,other,Not separately reimbursable,23.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.496,other,Not separately reimbursable,,,,116.04,other,Not separately reimbursable,2949.94,4601,
XR Femur 2 Views Left,4100375,CDM,320,RC,73552,HCPCS,OUTPATIENT,,,230,138,1-TC|2-LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,140.6,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,219.816,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.168,case rate,pays based on per visit rate,73.49,31.95,,127.8,Fee Schedule,31.95% of LA custom fee schedule,2950.94,4602,
Report,4100375,CDM,972,RC,73552,HCPCS,OUTPATIENT,,,95,57,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.36,other,Not separately reimbursable,,31.95,,224.416,other,Not separately reimbursable,23.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.144,other,Not separately reimbursable,,,,84.856,other,Not separately reimbursable,2951.94,4603,
XR Femur 2 Views Bilateral,4100375,CDM,320,RC,73552,HCPCS,OUTPATIENT,,,230,138,1-TC|2-LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,140.6,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,22.496,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.648,case rate,pays based on per visit rate,73.49,31.95,,127.8,Fee Schedule,31.95% of LA custom fee schedule,2952.94,4604,
XR Femur 2 Views Right,4100376,CDM,320,RC,73552,HCPCS,OUTPATIENT,,,230,138,1-TC|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,140.6,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,22.496,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.648,case rate,pays based on per visit rate,73.49,31.95,,127.8,Fee Schedule,31.95% of LA custom fee schedule,2953.94,4605,
Report,4100376,CDM,972,RC,73552,HCPCS,OUTPATIENT,,,95,57,1-TC|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,140.6,other,Not separately reimbursable,,31.95,,228.76,other,Not separately reimbursable,23.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.648,other,Not separately reimbursable,,,,127.8,other,Not separately reimbursable,2954.94,4606,
FMC XR Femur 2 Views Right,4100376,CDM,320,RC,73552,HCPCS,OUTPATIENT,,,230,138,1-TC|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,140.6,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,12.16,case rate,pays based on per visit rate,73.49,31.95,,127.8,Fee Schedule,31.95% of LA custom fee schedule,2955.94,4607,
Report,4100377,CDM,972,RC,73140,HCPCS,OUTPATIENT,,,21,12.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,140.6,other,Not separately reimbursable,,31.95,,23.16,other,Not separately reimbursable,21,100,,,fee schedule,100% of CMS physician fee schedule,,,,516.8,other,Not separately reimbursable,,,,127.8,other,Not separately reimbursable,2956.94,4608,
XR Finger Bilateral Profee,4100377,CDM,972,RC,73140,HCPCS,OUTPATIENT,,,21,12.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,101.232,other,Not separately reimbursable,,31.95,,23.16,other,Not separately reimbursable,21,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.688,other,Not separately reimbursable,,,,92.016,other,Not separately reimbursable,2957.94,4609,
XR Finger Left,4100378,CDM,320,RC,73140,HCPCS,OUTPATIENT,,,230,138,1-TC|2-LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,93.36,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.384,case rate,pays based on per visit rate,73.49,31.95,,84.856,Fee Schedule,31.95% of LA custom fee schedule,2958.94,4610,
Report,4100378,CDM,972,RC,73140,HCPCS,OUTPATIENT,,,21,12.6,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.36,other,Not separately reimbursable,,31.95,,23.16,other,Not separately reimbursable,21,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,84.856,other,Not separately reimbursable,2959.94,4611,
XR Finger Bilateral,4100378,CDM,320,RC,73140,HCPCS,OUTPATIENT,,,230,138,1-TC|2-LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,110.232,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.128,case rate,pays based on per visit rate,73.49,31.95,,100.192,Fee Schedule,31.95% of LA custom fee schedule,2960.94,4612,
XR Finger Right,4100379,CDM,320,RC,73140,HCPCS,OUTPATIENT,,,230,138,1-TC|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,12.768,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2961.94,4613,
Report,4100379,CDM,972,RC,73140,HCPCS,OUTPATIENT,,,21,12.6,1-TC|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.36,other,Not separately reimbursable,,31.95,,23.16,other,Not separately reimbursable,21,100,,,fee schedule,100% of CMS physician fee schedule,,,,424.688,other,Not separately reimbursable,,,,84.856,other,Not separately reimbursable,2962.94,4614,
FMC XR Finger Right,4100379,CDM,320,RC,73140,HCPCS,OUTPATIENT,,,230,138,1-TC|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.128,case rate,pays based on per visit rate,73.49,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2963.94,4615,
XR Fluoroscopy Up to 1 Hour,4100380,CDM,972,RC,76000,HCPCS,OUTPATIENT,,,55,33,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,59.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,23.16,other,Not separately reimbursable,24.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,54.416,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2964.94,4616,
XR Fluoroscopy Up to 1 Hour,4100380,CDM,320,RC,76000,HCPCS,OUTPATIENT,,,627,376.2,26,532.95,85,,426.36,Percent of total billed charges,85% of total billed charges,180.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,180.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,220.39,35.15,,93.36,fee schedule,35.15% of LA custom fee schedule,200.33,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,8.512,case rate,pays based on per visit rate,200.33,31.95,,84.856,Fee Schedule,31.95% of LA custom fee schedule,2965.94,4617,
XR Fluoroscopy Up to 1 Hour,4100380,CDM,320,RC,76000,HCPCS,OUTPATIENT,,,627,376.2,26,532.95,85,,426.36,Percent of total billed charges,85% of total billed charges,180.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,180.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,220.39,35.15,,13.2,fee schedule,35.15% of LA custom fee schedule,200.33,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,196.08,case rate,pays based on per visit rate,200.33,31.95,,12,Fee Schedule,31.95% of LA custom fee schedule,2966.94,4618,
XR Fluoroscopy Over 1 Hour,4100381,CDM,320,RC,77001,HCPCS,OUTPATIENT,,,250,150,TC,212.5,85,,170,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,93.36,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,23.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.04,case rate,pays based on per visit rate,79.88,31.95,,84.856,Fee Schedule,31.95% of LA custom fee schedule,2967.94,4619,
Report,4100382,CDM,972,RC,73620,HCPCS,OUTPATIENT,,,24,14.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.36,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,84.856,other,Not separately reimbursable,2968.94,4620,
XR Foot 2 Views Bilateral Profee,4100382,CDM,972,RC,73620,HCPCS,OUTPATIENT,,,24,14.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,13.2,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,1062.48,other,Not separately reimbursable,,,,12,other,Not separately reimbursable,2969.94,4621,
Report,4100383,CDM,972,RC,73620,HCPCS,OUTPATIENT,,,24,14.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.168,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,23.408,other,Not separately reimbursable,,,,6.52,other,Not separately reimbursable,2970.94,4622,
XR Foot 2 Views Left,4100383,CDM,320,RC,73620,HCPCS,OUTPATIENT,,,229,137.4,26,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.49,35.15,,50.616,fee schedule,35.15% of LA custom fee schedule,73.17,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,18.848,case rate,pays based on per visit rate,73.17,31.95,,46.008,Fee Schedule,31.95% of LA custom fee schedule,2971.94,4623,
XR Foot 2 Views Bilateral,4100383,CDM,320,RC,73620,HCPCS,OUTPATIENT,,,229,137.4,26,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.49,35.15,,93.08,fee schedule,35.15% of LA custom fee schedule,73.17,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,723.52,case rate,pays based on per visit rate,73.17,31.95,,84.6,Fee Schedule,31.95% of LA custom fee schedule,2972.94,4624,
Report,4100384,CDM,972,RC,73620,HCPCS,OUTPATIENT,,,24,14.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,76.208,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,21.28,other,Not separately reimbursable,,,,69.264,other,Not separately reimbursable,2973.94,4625,
XR Foot 2 Views Right,4100384,CDM,320,RC,73620,HCPCS,OUTPATIENT,,,229,137.4,26,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.49,35.15,,92.8,fee schedule,35.15% of LA custom fee schedule,73.17,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,4.408,case rate,pays based on per visit rate,73.17,31.95,,84.352,Fee Schedule,31.95% of LA custom fee schedule,2974.94,4626,
FMC XR Foot 2 Views Right,4100384,CDM,320,RC,73620,HCPCS,OUTPATIENT,,,229,137.4,26,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.49,35.15,,92.8,fee schedule,35.15% of LA custom fee schedule,73.17,31.95,,24.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.08,case rate,pays based on per visit rate,73.17,31.95,,84.352,Fee Schedule,31.95% of LA custom fee schedule,2975.94,4627,
Report,4100385,CDM,972,RC,73630,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,92.8,other,Not separately reimbursable,,31.95,,243.072,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.824,other,Not separately reimbursable,,,,84.352,other,Not separately reimbursable,2976.94,4628,
XR Foot Complete Bilateral Profee,4100385,CDM,972,RC,73630,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,50.616,other,Not separately reimbursable,,31.95,,248.952,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.64,other,Not separately reimbursable,,,,46.008,other,Not separately reimbursable,2977.94,4629,
Report,4100386,CDM,972,RC,73630,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,92.8,other,Not separately reimbursable,,31.95,,249.208,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.512,other,Not separately reimbursable,,,,84.352,other,Not separately reimbursable,2978.94,4630,
XR Foot Complete Left,4100386,CDM,320,RC,73630,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,50.896,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,254.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.08,case rate,pays based on per visit rate,73.49,31.95,,46.264,Fee Schedule,31.95% of LA custom fee schedule,2979.94,4631,
XR Foot Complete Bilateral,4100386,CDM,320,RC,73630,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,92.8,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,6.392,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,18.24,case rate,pays based on per visit rate,73.49,31.95,,84.352,Fee Schedule,31.95% of LA custom fee schedule,2980.94,4632,
Report,4100387,CDM,972,RC,73630,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,92.8,other,Not separately reimbursable,,31.95,,269.656,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,130.72,other,Not separately reimbursable,,,,84.352,other,Not separately reimbursable,2981.94,4633,
XR Foot Complete Right,4100387,CDM,320,RC,73630,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,75.928,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,292.408,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,74.176,case rate,pays based on per visit rate,73.49,31.95,,69.016,Fee Schedule,31.95% of LA custom fee schedule,2982.94,4634,
FMC XR Foot Complete Right,4100387,CDM,320,RC,73630,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,92.8,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,77.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.04,case rate,pays based on per visit rate,73.49,31.95,,84.352,Fee Schedule,31.95% of LA custom fee schedule,2983.94,4635,
Report,4100389,CDM,972,RC,73090,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,50.616,other,Not separately reimbursable,,31.95,,86.392,other,Not separately reimbursable,19.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,21.888,other,Not separately reimbursable,,,,46.008,other,Not separately reimbursable,2984.94,4636,
XR Forearm 2 Views Bilateral Profee,4100389,CDM,972,RC,73090,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,75.928,other,Not separately reimbursable,,31.95,,156.68,other,Not separately reimbursable,19.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.6,other,Not separately reimbursable,,,,69.016,other,Not separately reimbursable,2985.94,4637,
Report,4100390,CDM,972,RC,73090,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,50.896,other,Not separately reimbursable,,31.95,,181.728,other,Not separately reimbursable,19.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.288,other,Not separately reimbursable,,,,46.264,other,Not separately reimbursable,2986.94,4638,
XR Forearm 2 Views Left,4100390,CDM,320,RC,73090,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,15.608,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,28.936,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,8.208,case rate,pays based on per visit rate,73.49,31.95,,14.184,Fee Schedule,31.95% of LA custom fee schedule,2987.94,4639,
XR Forearm 2 Views Bilateral,4100390,CDM,320,RC,73090,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,58.488,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,33.736,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,7.6,case rate,pays based on per visit rate,73.49,31.95,,53.168,Fee Schedule,31.95% of LA custom fee schedule,2988.94,4640,
Report,4100391,CDM,972,RC,73090,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,50.896,other,Not separately reimbursable,,31.95,,36.12,other,Not separately reimbursable,19.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.896,other,Not separately reimbursable,,,,46.264,other,Not separately reimbursable,2989.94,4641,
XR Forearm 2 Views Right,4100391,CDM,320,RC,73090,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,15.608,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,37.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,130.72,case rate,pays based on per visit rate,73.49,31.95,,14.184,Fee Schedule,31.95% of LA custom fee schedule,2990.94,4642,
FMC XR Forearm 2 Views Right,4100391,CDM,320,RC,73090,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,123.728,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,68.248,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.168,case rate,pays based on per visit rate,73.49,31.95,,112.464,Fee Schedule,31.95% of LA custom fee schedule,2991.94,4643,
Report,4100392,CDM,972,RC,73120,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.608,other,Not separately reimbursable,,31.95,,72.848,other,Not separately reimbursable,20.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,14.184,other,Not separately reimbursable,2992.94,4644,
XR Hand 2 Views Bilateral Profee,4100392,CDM,972,RC,73120,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,50.616,other,Not separately reimbursable,,31.95,,86.392,other,Not separately reimbursable,20.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,76,other,Not separately reimbursable,,,,46.008,other,Not separately reimbursable,2993.94,4645,
Report,4100393,CDM,972,RC,73120,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.608,other,Not separately reimbursable,,31.95,,95.08,other,Not separately reimbursable,20.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,117.952,other,Not separately reimbursable,,,,14.184,other,Not separately reimbursable,2994.94,4646,
XR Hand 2 Views Left,4100393,CDM,320,RC,73120,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,15.608,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,96.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,209.76,case rate,pays based on per visit rate,73.49,31.95,,14.184,Fee Schedule,31.95% of LA custom fee schedule,2995.94,4647,
XR Hand 2 Views Bilateral,4100393,CDM,320,RC,73120,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,87.176,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,255.6,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.824,case rate,pays based on per visit rate,73.49,31.95,,79.24,Fee Schedule,31.95% of LA custom fee schedule,2996.94,4648,
Report,4100394,CDM,972,RC,73120,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.728,other,Not separately reimbursable,,31.95,,317.712,other,Not separately reimbursable,20.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.736,other,Not separately reimbursable,,,,10.656,other,Not separately reimbursable,2997.94,4649,
XR Hand 2 Views Right,4100394,CDM,320,RC,73120,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,94.2,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,318.224,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.432,case rate,pays based on per visit rate,73.49,31.95,,85.624,Fee Schedule,31.95% of LA custom fee schedule,2998.94,4650,
FMC XR Hand 2 Views Right,4100394,CDM,320,RC,73120,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,68.328,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,345.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.736,case rate,pays based on per visit rate,73.49,31.95,,62.112,Fee Schedule,31.95% of LA custom fee schedule,2999.94,4651,
Report,4100395,CDM,972,RC,73130,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,149.04,other,Not separately reimbursable,,31.95,,345.064,other,Not separately reimbursable,25.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.128,other,Not separately reimbursable,,,,135.472,other,Not separately reimbursable,3000.94,4652,
XR Hand Complete Bilateral Profee,4100395,CDM,972,RC,73130,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.728,other,Not separately reimbursable,,31.95,,345.064,other,Not separately reimbursable,25.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.592,other,Not separately reimbursable,,,,10.656,other,Not separately reimbursable,3001.94,4653,
Report,4100396,CDM,972,RC,73130,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,170.128,other,Not separately reimbursable,,31.95,,345.064,other,Not separately reimbursable,25.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,154.64,other,Not separately reimbursable,3002.94,4654,
XR Hand Complete Left,4100396,CDM,320,RC,73130,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,23.032,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,345.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,67.488,case rate,pays based on per visit rate,73.49,31.95,,20.936,Fee Schedule,31.95% of LA custom fee schedule,3003.94,4655,
XR Hand Complete Bilateral,4100396,CDM,320,RC,73130,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,23.032,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,383.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,106.704,case rate,pays based on per visit rate,73.49,31.95,,20.936,Fee Schedule,31.95% of LA custom fee schedule,3004.94,4656,
Report,4100397,CDM,972,RC,73130,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,440.08,other,Not separately reimbursable,,31.95,,383.4,other,Not separately reimbursable,25.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,105.488,other,Not separately reimbursable,,,,400.016,other,Not separately reimbursable,3005.94,4657,
XR Hand Complete Right,4100397,CDM,320,RC,73130,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,421.8,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,399.76,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1368,case rate,pays based on per visit rate,73.49,31.95,,383.4,Fee Schedule,31.95% of LA custom fee schedule,3006.94,4658,
FMC XR Hand Complete Right,4100397,CDM,320,RC,73130,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,440.08,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,408.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1368,case rate,pays based on per visit rate,73.49,31.95,,400.016,Fee Schedule,31.95% of LA custom fee schedule,3007.94,4659,
Report,4100398,CDM,972,RC,73650,HCPCS,OUTPATIENT,,,25,15,1-26|2-50,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,343.064,other,Not separately reimbursable,,31.95,,408.96,other,Not separately reimbursable,18.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.648,other,Not separately reimbursable,,,,311.832,other,Not separately reimbursable,3008.94,4660,
XR Calcaneous Bilateral Profee,4100398,CDM,972,RC,73650,HCPCS,OUTPATIENT,,,25,15,1-26|2-50,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,303.976,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,18.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,276.304,other,Not separately reimbursable,3009.94,4661,
Report,4100399,CDM,972,RC,73650,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,372.592,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,18.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.376,other,Not separately reimbursable,,,,338.672,other,Not separately reimbursable,3010.94,4662,
XR Calcaneous Left,4100399,CDM,320,RC,73650,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,103.512,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,0.304,case rate,pays based on per visit rate,73.49,31.95,,94.088,Fee Schedule,31.95% of LA custom fee schedule,3011.94,4663,
XR Calcaneous Bilateral,4100399,CDM,320,RC,73650,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,111.92,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,0.912,case rate,pays based on per visit rate,73.49,31.95,,101.728,Fee Schedule,31.95% of LA custom fee schedule,3012.94,4664,
XR Calcaneus Left,4100399,CDM,320,RC,73650,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,25.48,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.432,case rate,pays based on per visit rate,73.49,31.95,,23.16,Fee Schedule,31.95% of LA custom fee schedule,3013.94,4665,
Report,4100399,CDM,972,RC,73650,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.48,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,18.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,94.848,other,Not separately reimbursable,,,,23.16,other,Not separately reimbursable,3014.94,4666,
Report,4100400,CDM,972,RC,73650,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.48,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,18.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,12.16,other,Not separately reimbursable,,,,23.16,other,Not separately reimbursable,3015.94,4667,
XR Calcaneous Right,4100400,CDM,320,RC,73650,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,25.48,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,11.248,case rate,pays based on per visit rate,73.49,31.95,,23.16,Fee Schedule,31.95% of LA custom fee schedule,3016.94,4668,
XR Calcaneus Right,4100400,CDM,320,RC,73650,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,83.8,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.432,case rate,pays based on per visit rate,73.49,31.95,,76.168,Fee Schedule,31.95% of LA custom fee schedule,3017.94,4669,
Report,4100400,CDM,972,RC,73650,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,83.8,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,18.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.592,other,Not separately reimbursable,,,,76.168,other,Not separately reimbursable,3018.94,4670,
FMC XR Calcaneous Right,4100400,CDM,320,RC,73650,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,25.48,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.344,case rate,pays based on per visit rate,73.49,31.95,,23.16,Fee Schedule,31.95% of LA custom fee schedule,3019.94,4671,
XR Small Bowel,4100402,CDM,320,RC,74248,HCPCS,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,84.36,fee schedule,35.15% of LA custom fee schedule,111.83,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.648,case rate,pays based on per visit rate,111.83,31.95,,76.68,Fee Schedule,31.95% of LA custom fee schedule,3020.94,4672,
XR Small Bowel ProFee,4100402,CDM,972,RC,74248,HCPCS,OUTPATIENT,,,105,63,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,104.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.48,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,43.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,23.16,other,Not separately reimbursable,3021.94,4673,
Report,4100403,CDM,972,RC,73501,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.48,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,23.16,other,Not separately reimbursable,3022.94,4674,
XR Hip 1 View Left,4100403,CDM,320,RC,73501,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,50.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,25.48,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,0.912,case rate,pays based on per visit rate,73.49,31.95,,23.16,Fee Schedule,31.95% of LA custom fee schedule,3023.94,4675,
Report,4100404,CDM,972,RC,73501,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,506.16,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.952,other,Not separately reimbursable,,,,460.08,other,Not separately reimbursable,3024.94,4676,
XR Hip 1 View Right,4100404,CDM,320,RC,73501,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,50.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,50.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,25.48,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.072,case rate,pays based on per visit rate,73.49,31.95,,23.16,Fee Schedule,31.95% of LA custom fee schedule,3025.94,4677,
XR Fluoro Upper GI Single w/ Small Bowel,4100405,CDM,320,RC,74240,HCPCS,OUTPATIENT,,,605,363,TC,514.25,85,,411.4,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,212.66,35.15,,25.48,fee schedule,35.15% of LA custom fee schedule,193.3,31.95,,421.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,14.592,case rate,pays based on per visit rate,193.3,31.95,,23.16,Fee Schedule,31.95% of LA custom fee schedule,3026.94,4678,
XR Upper GI ProFee,4100405,CDM,972,RC,74240,HCPCS,OUTPATIENT,,,106,63.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.48,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,74.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,16.112,other,Not separately reimbursable,,,,23.16,other,Not separately reimbursable,3027.94,4679,
Report,4100406,CDM,972,RC,73060,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.48,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,21.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,17.328,other,Not separately reimbursable,,,,23.16,other,Not separately reimbursable,3028.94,4680,
XR Humerus Bilateral Profee,4100406,CDM,972,RC,73060,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,25.48,other,Not separately reimbursable,,31.95,,421.744,other,Not separately reimbursable,21.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.544,other,Not separately reimbursable,,,,23.16,other,Not separately reimbursable,3029.94,4681,
Report,4100407,CDM,972,RC,73060,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,28.12,other,Not separately reimbursable,,31.95,,424.808,other,Not separately reimbursable,21.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.368,other,Not separately reimbursable,,,,25.56,other,Not separately reimbursable,3030.94,4682,
XR Humerus Left,4100407,CDM,320,RC,73060,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,194.032,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,434.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,7.296,case rate,pays based on per visit rate,73.49,31.95,,176.368,Fee Schedule,31.95% of LA custom fee schedule,3031.94,4683,
XR Humerus Bilateral,4100407,CDM,320,RC,73060,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,39.904,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,434.52,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,9.728,case rate,pays based on per visit rate,73.49,31.95,,36.272,Fee Schedule,31.95% of LA custom fee schedule,3032.94,4684,
Report,4100408,CDM,972,RC,73060,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,208.088,other,Not separately reimbursable,,31.95,,444.744,other,Not separately reimbursable,21.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,189.144,other,Not separately reimbursable,3033.94,4685,
XR Humerus Right,4100408,CDM,320,RC,73060,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,157.472,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,444.744,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,7.6,case rate,pays based on per visit rate,73.49,31.95,,143.136,Fee Schedule,31.95% of LA custom fee schedule,3034.94,4686,
XR Humerus Right,4100408,CDM,320,RC,73060,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,157.472,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,446.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,15.2,case rate,pays based on per visit rate,73.49,31.95,,143.136,Fee Schedule,31.95% of LA custom fee schedule,3035.94,4687,
XR Fluoro Upper GI w/ Air,4100409,CDM,320,RC,74246,HCPCS,OUTPATIENT,,,605,363,TC,514.25,85,,411.4,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,212.66,35.15,,157.472,fee schedule,35.15% of LA custom fee schedule,193.3,31.95,,460.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,15.504,case rate,pays based on per visit rate,193.3,31.95,,143.136,Fee Schedule,31.95% of LA custom fee schedule,3036.94,4688,
XR Upper GI w/ Air ProFee,4100409,CDM,972,RC,74246,HCPCS,OUTPATIENT,,,107,64.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,210.056,other,Not separately reimbursable,,31.95,,460.08,other,Not separately reimbursable,85.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,190.936,other,Not separately reimbursable,3037.94,4689,
Report,4100410,CDM,972,RC,74400,HCPCS,OUTPATIENT,,,73,43.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,148.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,57.616,other,Not separately reimbursable,,31.95,,460.08,other,Not separately reimbursable,73,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,52.376,other,Not separately reimbursable,3038.94,4690,
XR IVP,4100410,CDM,320,RC,74400,HCPCS,OUTPATIENT,,,1031,618.6,26,876.35,85,,701.08,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.4,35.15,,57.616,fee schedule,35.15% of LA custom fee schedule,329.4,31.95,,460.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.52,case rate,pays based on per visit rate,329.4,31.95,,52.376,Fee Schedule,31.95% of LA custom fee schedule,3039.94,4691,
XR IVP,4100410,CDM,320,RC,74400,HCPCS,OUTPATIENT,,,1031,618.6,26,876.35,85,,701.08,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.4,35.15,,210.904,fee schedule,35.15% of LA custom fee schedule,329.4,31.95,,460.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.52,case rate,pays based on per visit rate,329.4,31.95,,191.704,Fee Schedule,31.95% of LA custom fee schedule,3040.94,4692,
Report,4100410,CDM,972,RC,74400,HCPCS,OUTPATIENT,,,73,43.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,148.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,79.72,other,Not separately reimbursable,,31.95,,460.08,other,Not separately reimbursable,73,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.472,other,Not separately reimbursable,,,,72.464,other,Not separately reimbursable,3041.94,4693,
XR IVP w/ Tomos,4100411,CDM,320,RC,74415,HCPCS,OUTPATIENT,,,1030,618,TC,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.05,35.15,,79.72,fee schedule,35.15% of LA custom fee schedule,329.09,31.95,,460.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.648,case rate,pays based on per visit rate,329.09,31.95,,72.464,Fee Schedule,31.95% of LA custom fee schedule,3042.94,4694,
Report,4100411,CDM,972,RC,74415,HCPCS,OUTPATIENT,,,73,43.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,168.72,other,Not separately reimbursable,,31.95,,460.08,other,Not separately reimbursable,73,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.6,other,Not separately reimbursable,,,,153.36,other,Not separately reimbursable,3043.94,4695,
Report,4100412,CDM,972,RC,73560,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,153.536,other,Not separately reimbursable,,31.95,,460.08,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,0.608,other,Not separately reimbursable,,,,139.56,other,Not separately reimbursable,3044.94,4696,
XR Knee One or Two Views Bilateral Profee,4100412,CDM,972,RC,73560,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,240.992,other,Not separately reimbursable,,31.95,,460.08,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.8,other,Not separately reimbursable,,,,219.048,other,Not separately reimbursable,3045.94,4697,
Report,4100413,CDM,972,RC,73560,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,306.512,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.8,other,Not separately reimbursable,,,,278.608,other,Not separately reimbursable,3046.94,4698,
XR Knee One or Two Views Left,4100413,CDM,320,RC,73560,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,328.72,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.8,case rate,pays based on per visit rate,73.49,31.95,,298.8,Fee Schedule,31.95% of LA custom fee schedule,3047.94,4699,
XR Knee One or Two Views Bilateral,4100413,CDM,320,RC,73560,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,253.08,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,136.8,case rate,pays based on per visit rate,73.49,31.95,,230.04,Fee Schedule,31.95% of LA custom fee schedule,3048.94,4700,
Report,4100414,CDM,972,RC,73560,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,329.008,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,25.84,other,Not separately reimbursable,,,,299.056,other,Not separately reimbursable,3049.94,4701,
XR Knee One or Two Views Right,4100414,CDM,320,RC,73560,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,224.12,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.128,case rate,pays based on per visit rate,73.49,31.95,,203.712,Fee Schedule,31.95% of LA custom fee schedule,3050.94,4702,
FMC XR Knee One or Two Views Right,4100414,CDM,320,RC,73560,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,224.12,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.432,case rate,pays based on per visit rate,73.49,31.95,,203.712,Fee Schedule,31.95% of LA custom fee schedule,3051.94,4703,
Report,4100415,CDM,972,RC,73562,HCPCS,OUTPATIENT,,,30,18,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,32.408,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.2,other,Not separately reimbursable,,,,29.464,other,Not separately reimbursable,3052.94,4704,
XR Knee 3 Views Bilateral Profee,4100415,CDM,972,RC,73562,HCPCS,OUTPATIENT,,,30,18,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,224.12,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,203.712,other,Not separately reimbursable,3053.94,4705,
Report,4100416,CDM,972,RC,73562,HCPCS,OUTPATIENT,,,30,18,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,224.12,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,203.712,other,Not separately reimbursable,3054.94,4706,
XR Knee 3 Views Left,4100416,CDM,320,RC,73562,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,224.12,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.472,case rate,pays based on per visit rate,73.49,31.95,,203.712,Fee Schedule,31.95% of LA custom fee schedule,3055.94,4707,
XR Knee 3 Views Bilateral,4100416,CDM,320,RC,73562,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,76.36,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,247.152,case rate,pays based on per visit rate,73.49,31.95,,69.408,Fee Schedule,31.95% of LA custom fee schedule,3056.94,4708,
Report,4100417,CDM,972,RC,73562,HCPCS,OUTPATIENT,,,30,18,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,76.36,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.2,other,Not separately reimbursable,,,,69.408,other,Not separately reimbursable,3057.94,4709,
XR Knee 3 Views Right,4100417,CDM,320,RC,73562,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,328.72,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,24.32,case rate,pays based on per visit rate,73.49,31.95,,298.8,Fee Schedule,31.95% of LA custom fee schedule,3058.94,4710,
FMC XR Knee 3 Views Right,4100417,CDM,320,RC,73562,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,93.488,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.128,case rate,pays based on per visit rate,73.49,31.95,,84.976,Fee Schedule,31.95% of LA custom fee schedule,3059.94,4711,
Report,4100418,CDM,972,RC,73564,HCPCS,OUTPATIENT,,,37,22.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.488,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,31.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,307.04,other,Not separately reimbursable,,,,84.976,other,Not separately reimbursable,3060.94,4712,
XR Knee Complete Bilateral Profee,4100418,CDM,972,RC,73564,HCPCS,OUTPATIENT,,,37,22.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,93.488,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,31.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.384,other,Not separately reimbursable,,,,84.976,other,Not separately reimbursable,3061.94,4713,
Report,4100419,CDM,972,RC,73564,HCPCS,OUTPATIENT,,,37,22.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,48.04,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,31.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,43.672,other,Not separately reimbursable,3062.94,4714,
XR Knee Complete Left,4100419,CDM,320,RC,73564,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,229.744,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,576.08,case rate,pays based on per visit rate,73.49,31.95,,208.824,Fee Schedule,31.95% of LA custom fee schedule,3063.94,4715,
XR Knee Complete Bilateral,4100419,CDM,320,RC,73564,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,11.728,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,11.856,case rate,pays based on per visit rate,73.49,31.95,,10.656,Fee Schedule,31.95% of LA custom fee schedule,3064.94,4716,
Report,4100420,CDM,972,RC,73564,HCPCS,OUTPATIENT,,,37,22.2,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.416,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,31.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,104.88,other,Not separately reimbursable,,,,1.288,other,Not separately reimbursable,3065.94,4717,
XR Knee Complete Right,4100420,CDM,320,RC,73564,HCPCS,OUTPATIENT,,,230,138,1-26|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,47.688,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,79.04,case rate,pays based on per visit rate,73.49,31.95,,43.344,Fee Schedule,31.95% of LA custom fee schedule,3066.94,4718,
FMC XR Knee Complete Right,4100420,CDM,320,RC,73564,HCPCS,OUTPATIENT,,,230,138,1-26|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,47.688,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.736,case rate,pays based on per visit rate,73.49,31.95,,43.344,Fee Schedule,31.95% of LA custom fee schedule,3067.94,4719,
Report,4100421,CDM,972,RC,73580,HCPCS,OUTPATIENT,,,84,50.4,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,158.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,47.688,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,70.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.56,other,Not separately reimbursable,,,,43.344,other,Not separately reimbursable,3068.94,4720,
Report,4100421,CDM,972,RC,73580,HCPCS,OUTPATIENT,,,84,50.4,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,158.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,47.688,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,70.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,310.08,other,Not separately reimbursable,,,,43.344,other,Not separately reimbursable,3069.94,4721,
XR Arthrogram Knee Left,4100421,CDM,320,RC,73580,HCPCS,OUTPATIENT,,,1357,814.2,1-26|2-RT,1153.45,85,,922.76,Percent of total billed charges,85% of total billed charges,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.99,35.15,,55.72,fee schedule,35.15% of LA custom fee schedule,433.56,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,65.968,case rate,pays based on per visit rate,433.56,31.95,,50.648,Fee Schedule,31.95% of LA custom fee schedule,3070.94,4722,
XR Arthrogram Knee Right,4100421,CDM,320,RC,73580,HCPCS,OUTPATIENT,,,1357,814.2,1-26|2-RT,1153.45,85,,922.76,Percent of total billed charges,85% of total billed charges,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,474.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.99,35.15,,55.72,fee schedule,35.15% of LA custom fee schedule,433.56,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,333.184,case rate,pays based on per visit rate,433.56,31.95,,50.648,Fee Schedule,31.95% of LA custom fee schedule,3071.94,4723,
Report,4100422,CDM,972,RC,73565,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,55.72,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,333.184,other,Not separately reimbursable,,,,50.648,other,Not separately reimbursable,3072.94,4724,
XR Knee Standing AP Bilateral,4100422,CDM,320,RC,73565,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,55.72,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.12,case rate,pays based on per visit rate,73.49,31.95,,50.648,Fee Schedule,31.95% of LA custom fee schedule,3073.94,4725,
XR Nephrostogram/Loopogram,4100423,CDM,320,RC,74425,HCPCS,OUTPATIENT,,,1030,618,TC,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.05,35.15,,469.608,fee schedule,35.15% of LA custom fee schedule,329.09,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.32,case rate,pays based on per visit rate,329.09,31.95,,426.856,Fee Schedule,31.95% of LA custom fee schedule,3074.94,4726,
Report,4100423,CDM,972,RC,74425,HCPCS,OUTPATIENT,,,73,43.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,88.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,54.64,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,73,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.168,other,Not separately reimbursable,,,,49.664,other,Not separately reimbursable,3075.94,4727,
Report,4100424,CDM,972,RC,73592,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,469.608,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.432,other,Not separately reimbursable,,,,426.856,other,Not separately reimbursable,3076.94,4728,
XR LE Infant Min 2 Views Bilateral Profee,4100424,CDM,972,RC,73592,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,54.64,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.12,other,Not separately reimbursable,,,,49.664,other,Not separately reimbursable,3077.94,4729,
XR LE Infant Min 2 Views Left,4100425,CDM,320,RC,73592,HCPCS,OUTPATIENT,,,175,105,1-TC|2-LT,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,463.984,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,17.024,case rate,pays based on per visit rate,55.91,31.95,,421.744,Fee Schedule,31.95% of LA custom fee schedule,3078.94,4730,
Report,4100425,CDM,972,RC,73592,HCPCS,OUTPATIENT,,,25,15,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,54.64,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,49.664,other,Not separately reimbursable,3079.94,4731,
XR LE Infant Min 2 Views Bilateral,4100425,CDM,320,RC,73592,HCPCS,OUTPATIENT,,,175,105,1-TC|2-LT,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,46.712,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.04,case rate,pays based on per visit rate,55.91,31.95,,42.456,Fee Schedule,31.95% of LA custom fee schedule,3080.94,4732,
XR LE Infant Min 2 Views Right,4100426,CDM,320,RC,73592,HCPCS,OUTPATIENT,,,175,105,1-TC|2-RT,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,54.64,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.04,case rate,pays based on per visit rate,55.91,31.95,,49.664,Fee Schedule,31.95% of LA custom fee schedule,3081.94,4733,
Report,4100426,CDM,972,RC,73592,HCPCS,OUTPATIENT,,,25,15,1-TC|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,33.616,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,30.56,other,Not separately reimbursable,3082.94,4734,
FMC XR LE Infant Min 2 Views Right,4100426,CDM,320,RC,73592,HCPCS,OUTPATIENT,,,175,105,1-TC|2-RT,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,33.616,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.04,case rate,pays based on per visit rate,55.91,31.95,,30.56,Fee Schedule,31.95% of LA custom fee schedule,3083.94,4735,
XR Lumbar Puncture,4100427,CDM,320,RC,77003,HCPCS,OUTPATIENT,,,159,95.4,TC,135.15,85,,108.12,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.89,35.15,,350.096,fee schedule,35.15% of LA custom fee schedule,50.8,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.04,case rate,pays based on per visit rate,50.8,31.95,,318.224,Fee Schedule,31.95% of LA custom fee schedule,3084.94,4736,
Report,4100427,CDM,972,RC,77003,HCPCS,OUTPATIENT,,,91,54.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,118.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,33.616,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,67.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,30.56,other,Not separately reimbursable,3085.94,4737,
Report,4100428,CDM,972,RC,72110,HCPCS,OUTPATIENT,,,49,29.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,64.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,33.616,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,34.91,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,30.56,other,Not separately reimbursable,3086.94,4738,
XR Spine Lumbosacral Minimum 4 Views,4100428,CDM,320,RC,72110,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,33.616,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,30.096,case rate,pays based on per visit rate,116.3,31.95,,30.56,Fee Schedule,31.95% of LA custom fee schedule,3087.94,4739,
Report,4100429,CDM,972,RC,72100,HCPCS,OUTPATIENT,,,35,21,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,502.784,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,25.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,302.176,other,Not separately reimbursable,,,,457.016,other,Not separately reimbursable,3088.94,4740,
XR Spine Lumbosacral 2 or 3 Views,4100429,CDM,320,RC,72100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,502.784,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,126.464,case rate,pays based on per visit rate,73.49,31.95,,457.016,Fee Schedule,31.95% of LA custom fee schedule,3089.94,4741,
XR Spine Lumbosacral Bending Only,4100430,CDM,320,RC,72120,HCPCS,OUTPATIENT,,,364,218.4,TC,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,401.552,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,498.424,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.072,case rate,pays based on per visit rate,116.3,31.95,,365,Fee Schedule,31.95% of LA custom fee schedule,3090.94,4742,
Report,4100430,CDM,972,RC,72120,HCPCS,OUTPATIENT,,,37,22.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,502.784,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,26.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,21.888,other,Not separately reimbursable,,,,457.016,other,Not separately reimbursable,3091.94,4743,
Report,4100431,CDM,972,RC,72114,HCPCS,OUTPATIENT,,,51,30.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,578.992,other,Not separately reimbursable,,31.95,,498.424,other,Not separately reimbursable,41.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,80.256,other,Not separately reimbursable,,,,526.28,other,Not separately reimbursable,3092.94,4744,
XR Spine Lumbosacral Complete w/ Bending,4100431,CDM,320,RC,72114,HCPCS,OUTPATIENT,,,275,165,26,233.75,85,,187,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,502.784,fee schedule,35.15% of LA custom fee schedule,87.86,31.95,,2596.384,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,139.84,case rate,pays based on per visit rate,87.86,31.95,,457.016,Fee Schedule,31.95% of LA custom fee schedule,3093.94,4745,
Report,4100434,CDM,972,RC,70100,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,502.784,other,Not separately reimbursable,,31.95,,518.872,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,106.4,other,Not separately reimbursable,,,,457.016,other,Not separately reimbursable,3094.94,4746,
XR Mandible Partial Less Than 4 Views,4100434,CDM,320,RC,70100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,611.608,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,518.872,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,139.536,case rate,pays based on per visit rate,73.49,31.95,,555.928,Fee Schedule,31.95% of LA custom fee schedule,3095.94,4747,
XR Mandible Complete Min 4 Views Left,4100434,CDM,320,RC,70110,HCPCS,OUTPATIENT,,,380,228,26,323,85,,258.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,50.184,fee schedule,35.15% of LA custom fee schedule,121.41,31.95,,535.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,31.616,case rate,pays based on per visit rate,121.41,31.95,,45.616,Fee Schedule,31.95% of LA custom fee schedule,3096.94,4748,
Report,4100434,CDM,972,RC,70110,HCPCS,OUTPATIENT,,,38,22.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,50.184,other,Not separately reimbursable,,31.95,,555.928,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,35.568,other,Not separately reimbursable,,,,45.616,other,Not separately reimbursable,3097.94,4749,
XR Mandible Complete Min 4 Views Right,4100434,CDM,320,RC,70110,HCPCS,OUTPATIENT,,,380,228,26,323,85,,258.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,23.904,fee schedule,35.15% of LA custom fee schedule,121.41,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,41.648,case rate,pays based on per visit rate,121.41,31.95,,21.728,Fee Schedule,31.95% of LA custom fee schedule,3098.94,4750,
Report,4100435,CDM,972,RC,70110,HCPCS,OUTPATIENT,,,38,22.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,132.728,other,Not separately reimbursable,,31.95,,555.928,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,85.728,other,Not separately reimbursable,,,,120.64,other,Not separately reimbursable,3099.94,4751,
XR Mandible Complete Minimum 4 Views Right,4100435,CDM,320,RC,70110,HCPCS,OUTPATIENT,,,380,228,26,323,85,,258.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,84.36,fee schedule,35.15% of LA custom fee schedule,121.41,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,85.728,case rate,pays based on per visit rate,121.41,31.95,,76.68,Fee Schedule,31.95% of LA custom fee schedule,3100.94,4752,
Report,4100435,CDM,972,RC,70110,HCPCS,OUTPATIENT,,,38,22.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,140.04,other,Not separately reimbursable,,31.95,,555.928,other,Not separately reimbursable,28.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,88.768,other,Not separately reimbursable,,,,127.288,other,Not separately reimbursable,3101.94,4753,
XR Mandible Partial < 4 Views Left,4100436,CDM,320,RC,70100,HCPCS,OUTPATIENT,,,230,138,1-TC|2-LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,137.792,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,118.256,case rate,pays based on per visit rate,73.49,31.95,,125.248,Fee Schedule,31.95% of LA custom fee schedule,3102.94,4754,
Report,4100436,CDM,972,RC,70100,HCPCS,OUTPATIENT,,,28,16.8,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.808,other,Not separately reimbursable,,31.95,,555.928,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,85.728,other,Not separately reimbursable,,,,10.736,other,Not separately reimbursable,3103.94,4755,
XR Mandible Partial < 4 Views Right,4100437,CDM,320,RC,70100,HCPCS,OUTPATIENT,,,230,138,1-TC|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,11.808,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,118.256,case rate,pays based on per visit rate,73.49,31.95,,10.736,Fee Schedule,31.95% of LA custom fee schedule,3104.94,4756,
Report,4100437,CDM,972,RC,70100,HCPCS,OUTPATIENT,,,28,16.8,1-TC|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,11.808,other,Not separately reimbursable,,31.95,,555.928,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,88.16,other,Not separately reimbursable,,,,10.736,other,Not separately reimbursable,3105.94,4757,
Report,4100438,CDM,972,RC,70130,HCPCS,OUTPATIENT,,,52,31.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,240.424,other,Not separately reimbursable,,31.95,,555.928,other,Not separately reimbursable,40.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,218.536,other,Not separately reimbursable,3106.94,4758,
XR Mastoids Complete Bilateral,4100438,CDM,320,RC,70130,HCPCS,OUTPATIENT,,,380,228,26,323,85,,258.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,239.024,fee schedule,35.15% of LA custom fee schedule,121.41,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,19.76,case rate,pays based on per visit rate,121.41,31.95,,217.264,Fee Schedule,31.95% of LA custom fee schedule,3107.94,4759,
FMC XR Mastoids Complete Right,4100438,CDM,320,RC,70130,HCPCS,OUTPATIENT,,,380,228,26,323,85,,258.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,281.2,fee schedule,35.15% of LA custom fee schedule,121.41,31.95,,555.928,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,19.76,case rate,pays based on per visit rate,121.41,31.95,,255.6,Fee Schedule,31.95% of LA custom fee schedule,3108.94,4760,
XR Mastoids Complete Bilateral Profee,4100438,CDM,972,RC,70130,HCPCS,OUTPATIENT,,,52,31.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,281.2,other,Not separately reimbursable,,31.95,,613.44,other,Not separately reimbursable,40.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,19.76,other,Not separately reimbursable,,,,255.6,other,Not separately reimbursable,3109.94,4761,
Report,4100439,CDM,972,RC,70120,HCPCS,OUTPATIENT,,,28,16.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,392.272,other,Not separately reimbursable,,31.95,,651.784,other,Not separately reimbursable,26.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,882.512,other,Not separately reimbursable,,,,356.56,other,Not separately reimbursable,3110.94,4762,
XR Mastoids < 3 Views Bilateral,4100439,CDM,320,RC,70120,HCPCS,OUTPATIENT,,,180,108,1-26|2-LT,153,85,,122.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,320.288,fee schedule,35.15% of LA custom fee schedule,57.51,31.95,,651.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,994.08,case rate,pays based on per visit rate,57.51,31.95,,291.128,Fee Schedule,31.95% of LA custom fee schedule,3111.94,4763,
XR Mastoids < 3 Views Left,4100439,CDM,320,RC,70120,HCPCS,OUTPATIENT,,,180,108,1-26|2-LT,153,85,,122.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,241.832,fee schedule,35.15% of LA custom fee schedule,57.51,31.95,,651.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,150.176,case rate,pays based on per visit rate,57.51,31.95,,219.816,Fee Schedule,31.95% of LA custom fee schedule,3112.94,4764,
Report,4100440,CDM,972,RC,70120,HCPCS,OUTPATIENT,,,28,16.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,32.968,other,Not separately reimbursable,,31.95,,651.784,other,Not separately reimbursable,26.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.04,other,Not separately reimbursable,,,,29.968,other,Not separately reimbursable,3113.94,4765,
XR Mastoids < 3 Views Right,4100440,CDM,320,RC,70120,HCPCS,OUTPATIENT,,,180,108,1-26|2-RT,153,85,,122.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,32.968,fee schedule,35.15% of LA custom fee schedule,57.51,31.95,,651.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,163.552,case rate,pays based on per visit rate,57.51,31.95,,29.968,Fee Schedule,31.95% of LA custom fee schedule,3114.94,4766,
FMC XR Mastoids < 3 Views Right,4100440,CDM,320,RC,70120,HCPCS,OUTPATIENT,,,180,108,1-26|2-RT,153,85,,122.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,32.968,fee schedule,35.15% of LA custom fee schedule,57.51,31.95,,651.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1764.72,case rate,pays based on per visit rate,57.51,31.95,,29.968,Fee Schedule,31.95% of LA custom fee schedule,3115.94,4767,
Report,4100441,CDM,972,RC,77075,HCPCS,OUTPATIENT,,,81,48.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,115.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,156.696,other,Not separately reimbursable,,31.95,,651.784,other,Not separately reimbursable,64.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,27.36,other,Not separately reimbursable,,,,142.432,other,Not separately reimbursable,3116.94,4768,
XR Bone Survey Complete (Mets),4100441,CDM,320,RC,77075,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,156.696,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,651.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,118.256,case rate,pays based on per visit rate,116.3,31.95,,142.432,Fee Schedule,31.95% of LA custom fee schedule,3117.94,4769,
Report,4100442,CDM,972,RC,70160,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1635.176,other,Not separately reimbursable,,31.95,,651.784,other,Not separately reimbursable,26.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,88.16,other,Not separately reimbursable,,,,1486.312,other,Not separately reimbursable,3118.94,4770,
XR Nasal Bones Minimum 3 Views,4100442,CDM,320,RC,70160,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,1010.912,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,651.784,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,118.256,case rate,pays based on per visit rate,73.49,31.95,,918.88,Fee Schedule,31.95% of LA custom fee schedule,3119.94,4771,
XR Foreign Body Loc Nose/Rectum Child,4100443,CDM,320,RC,76010,HCPCS,OUTPATIENT,,,375,225,TC,318.75,85,,255,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,131.81,35.15,,1010.912,fee schedule,35.15% of LA custom fee schedule,119.81,31.95,,664.048,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1003.2,case rate,pays based on per visit rate,119.81,31.95,,918.88,Fee Schedule,31.95% of LA custom fee schedule,3120.94,4772,
Report,4100443,CDM,972,RC,76010,HCPCS,OUTPATIENT,,,28,16.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,34.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,156.696,other,Not separately reimbursable,,31.95,,690.12,other,Not separately reimbursable,18.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,127.68,other,Not separately reimbursable,,,,142.432,other,Not separately reimbursable,3121.94,4773,
Report,4100444,CDM,972,RC,74300,HCPCS,OUTPATIENT,,,76,45.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,88.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1017.104,other,Not separately reimbursable,,31.95,,690.12,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,127.68,other,Not separately reimbursable,,,,924.504,other,Not separately reimbursable,3122.94,4774,
XR Cholangiogram in OR,4100444,CDM,320,RC,74300,HCPCS,OUTPATIENT,,,475,285,26,403.75,85,,323,Percent of total billed charges,85% of total billed charges,230.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,230.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,166.96,35.15,,1012.32,fee schedule,35.15% of LA custom fee schedule,151.76,31.95,,690.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,907.44,case rate,pays based on per visit rate,151.76,31.95,,920.16,Fee Schedule,31.95% of LA custom fee schedule,3123.94,4775,
Report,4100445,CDM,972,RC,74290,HCPCS,OUTPATIENT,,,49,29.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,156.696,other,Not separately reimbursable,,31.95,,690.12,other,Not separately reimbursable,49,100,,,fee schedule,100% of CMS physician fee schedule,,,,22.8,other,Not separately reimbursable,,,,142.432,other,Not separately reimbursable,3124.94,4776,
XR Cholecystography (GB) Oral Contrast,4100445,CDM,320,RC,74290,HCPCS,OUTPATIENT,,,407,244.2,26,345.95,85,,276.76,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,143.06,35.15,,1012.32,fee schedule,35.15% of LA custom fee schedule,130.04,31.95,,690.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,20.064,case rate,pays based on per visit rate,130.04,31.95,,920.16,Fee Schedule,31.95% of LA custom fee schedule,3125.94,4777,
Report,4100446,CDM,972,RC,70200,HCPCS,OUTPATIENT,,,42,25.2,50,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,156.696,other,Not separately reimbursable,,31.95,,690.12,other,Not separately reimbursable,30.51,100,,,fee schedule,100% of CMS physician fee schedule,,,,59.28,other,Not separately reimbursable,,,,142.432,other,Not separately reimbursable,3126.94,4778,
XR Orbits Complete Bilateral,4100446,CDM,320,RC,70200,HCPCS,OUTPATIENT,,,230,138,50,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,10.936,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,690.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,163.552,case rate,pays based on per visit rate,73.49,31.95,,9.936,Fee Schedule,31.95% of LA custom fee schedule,3127.94,4779,
XR Orbits Complete Bilateral Profee,4100446,CDM,972,RC,70200,HCPCS,OUTPATIENT,,,42,25.2,50,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,109.384,other,Not separately reimbursable,,31.95,,690.12,other,Not separately reimbursable,30.51,100,,,fee schedule,100% of CMS physician fee schedule,,,,191.216,other,Not separately reimbursable,,,,99.432,other,Not separately reimbursable,3128.94,4780,
Report,4100447,CDM,972,RC,72170,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,109.384,other,Not separately reimbursable,,31.95,,690.12,other,Not separately reimbursable,17.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,79.04,other,Not separately reimbursable,,,,99.432,other,Not separately reimbursable,3129.94,4781,
XR Pelvis 1 or 2 Views,4100447,CDM,320,RC,72170,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,10.936,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,690.12,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,79.04,case rate,pays based on per visit rate,73.49,31.95,,9.936,Fee Schedule,31.95% of LA custom fee schedule,3130.94,4782,
Report,4100449,CDM,972,RC,72190,HCPCS,OUTPATIENT,,,34,20.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,132.168,other,Not separately reimbursable,,31.95,,690.12,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,363.888,other,Not separately reimbursable,,,,120.136,other,Not separately reimbursable,3131.94,4783,
XR Pelvis Complete Minimum 3 Views,4100449,CDM,320,RC,72190,HCPCS,OUTPATIENT,,,200,120,26,170,85,,136,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,109.384,fee schedule,35.15% of LA custom fee schedule,63.9,31.95,,691.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,79.04,case rate,pays based on per visit rate,63.9,31.95,,99.432,Fee Schedule,31.95% of LA custom fee schedule,3132.94,4784,
Report,4100450,CDM,972,RC,74420,HCPCS,OUTPATIENT,,,54,32.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,133.568,other,Not separately reimbursable,,31.95,,691.4,other,Not separately reimbursable,47.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,58.672,other,Not separately reimbursable,,,,121.408,other,Not separately reimbursable,3133.94,4785,
XR Urography Retrograde,4100450,CDM,320,RC,74420,HCPCS,OUTPATIENT,,,1031,618.6,26,876.35,85,,701.08,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.4,35.15,,130.192,fee schedule,35.15% of LA custom fee schedule,329.4,31.95,,691.4,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,52.592,case rate,pays based on per visit rate,329.4,31.95,,118.344,Fee Schedule,31.95% of LA custom fee schedule,3134.94,4786,
XR Urography Retrograde,4100450,CDM,320,RC,74420,HCPCS,OUTPATIENT,,,1031,618.6,26,876.35,85,,701.08,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.4,35.15,,112.48,fee schedule,35.15% of LA custom fee schedule,329.4,31.95,,718.24,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,60.8,case rate,pays based on per visit rate,329.4,31.95,,102.24,Fee Schedule,31.95% of LA custom fee schedule,3135.94,4787,
Report,4100450,CDM,972,RC,74420,HCPCS,OUTPATIENT,,,54,32.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,109.384,other,Not separately reimbursable,,31.95,,741.24,other,Not separately reimbursable,47.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,1915.2,other,Not separately reimbursable,,,,99.432,other,Not separately reimbursable,3136.94,4788,
XR Urography Retrograde Charge,4100450,CDM,320,RC,74420,HCPCS,OUTPATIENT,,,1031,618.6,26,876.35,85,,701.08,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.4,35.15,,133.568,fee schedule,35.15% of LA custom fee schedule,329.4,31.95,,766.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.216,case rate,pays based on per visit rate,329.4,31.95,,121.408,Fee Schedule,31.95% of LA custom fee schedule,3137.94,4789,
Report,4100451,CDM,972,RC,71111,HCPCS,OUTPATIENT,,,49,29.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,61.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.936,other,Not separately reimbursable,,31.95,,817.92,other,Not separately reimbursable,32.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.52,other,Not separately reimbursable,,,,9.936,other,Not separately reimbursable,3138.94,4790,
XR Ribs w/ PA Chest Bilateral,4100451,CDM,320,RC,71111,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,10.936,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,843.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,22.192,case rate,pays based on per visit rate,116.3,31.95,,9.936,Fee Schedule,31.95% of LA custom fee schedule,3139.94,4791,
XR Ribs 3 Views Bilateral,4100452,CDM,320,RC,71110,HCPCS,OUTPATIENT,,,364,218.4,TC,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,10.936,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,843.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.648,case rate,pays based on per visit rate,116.3,31.95,,9.936,Fee Schedule,31.95% of LA custom fee schedule,3140.94,4792,
Report,4100452,CDM,972,RC,71110,HCPCS,OUTPATIENT,,,41,24.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,51.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,133.568,other,Not separately reimbursable,,31.95,,849.872,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,1732.8,other,Not separately reimbursable,,,,121.408,other,Not separately reimbursable,3141.94,4793,
Report,4100453,CDM,972,RC,71101,HCPCS,OUTPATIENT,,,40,24,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,10.936,other,Not separately reimbursable,,31.95,,894.6,other,Not separately reimbursable,26.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,8.816,other,Not separately reimbursable,,,,9.936,other,Not separately reimbursable,3142.94,4794,
XR Ribs w/ PA Chest Left,4100453,CDM,320,RC,71101,HCPCS,OUTPATIENT,,,364,218.4,1-26|2-LT,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,10.936,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,383.344,case rate,pays based on per visit rate,116.3,31.95,,9.936,Fee Schedule,31.95% of LA custom fee schedule,3143.94,4795,
Report,4100454,CDM,972,RC,71101,HCPCS,OUTPATIENT,,,40,24,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,7.824,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,26.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,228,other,Not separately reimbursable,,,,7.112,other,Not separately reimbursable,3144.94,4796,
XR Ribs w/ PA Chest Right,4100454,CDM,320,RC,71101,HCPCS,OUTPATIENT,,,364,218.4,1-26|2-RT,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,11.44,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,196.08,case rate,pays based on per visit rate,116.3,31.95,,10.4,Fee Schedule,31.95% of LA custom fee schedule,3145.94,4797,
Report,4100455,CDM,972,RC,71100,HCPCS,OUTPATIENT,,,34,20.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,634.384,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,261.744,other,Not separately reimbursable,,,,576.632,other,Not separately reimbursable,3146.94,4798,
XR Ribs 2 Views Left,4100455,CDM,320,RC,71100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,634.104,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,410.4,case rate,pays based on per visit rate,73.49,31.95,,576.376,Fee Schedule,31.95% of LA custom fee schedule,3147.94,4799,
Report,4100456,CDM,972,RC,71100,HCPCS,OUTPATIENT,,,34,20.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,23.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.984,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3148.94,4800,
XR Ribs 2 Views Right,4100456,CDM,320,RC,71100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,53.2,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3149.94,4801,
Report,4100457,CDM,972,RC,72202,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,127.944,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,25.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,53.2,other,Not separately reimbursable,,,,116.296,other,Not separately reimbursable,3150.94,4802,
XR Sacroiliac Joints Minimum 3 Views,4100457,CDM,320,RC,72202,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,53.2,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3151.94,4803,
Report,4100458,CDM,972,RC,72200,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,22.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,53.2,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3152.94,4804,
XR Sacroiliac Joints 1 or 2 Views,4100458,CDM,320,RC,72200,HCPCS,OUTPATIENT,,,229,137.4,26,194.65,85,,155.72,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.49,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.17,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,34.96,case rate,pays based on per visit rate,73.17,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3153.94,4805,
XR Sacrum and Coccyx,4100459,CDM,320,RC,72220,HCPCS,OUTPATIENT,,,230,138,TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,17.328,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3154.94,4806,
Report,4100459,CDM,972,RC,72220,HCPCS,OUTPATIENT,,,27,16.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,21.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,216.752,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3155.94,4807,
Report,4100460,CDM,972,RC,73010,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,13.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,173.28,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3156.94,4808,
XR Scapula Bilateral Profee,4100460,CDM,972,RC,73010,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,228.616,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,13.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,38,other,Not separately reimbursable,,,,207.8,other,Not separately reimbursable,3157.94,4809,
Report,4100461,CDM,972,RC,73010,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,129.352,other,Not separately reimbursable,,31.95,,920.16,other,Not separately reimbursable,13.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,176.928,other,Not separately reimbursable,,,,117.576,other,Not separately reimbursable,3158.94,4810,
XR Scapula Left,4100461,CDM,320,RC,73010,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,920.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,469.68,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3159.94,4811,
XR Scapula Bilateral,4100461,CDM,320,RC,73010,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,940.608,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,421.648,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3160.94,4812,
Report,4100462,CDM,972,RC,73010,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,996.84,other,Not separately reimbursable,13.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,1900,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3161.94,4813,
XR Scapula Right,4100462,CDM,320,RC,73010,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,996.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,307.04,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3162.94,4814,
FMC XR Scapula Right,4100462,CDM,320,RC,73010,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,161.12,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3163.94,4815,
Report,4100464,CDM,972,RC,73020,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1035.184,other,Not separately reimbursable,12.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,130.416,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3164.94,4816,
XR Shoulder 1 View Left,4100464,CDM,320,RC,73020,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,130.416,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3165.94,4817,
Report,4100465,CDM,972,RC,73020,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1035.184,other,Not separately reimbursable,12.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,96.672,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3166.94,4818,
XR Shoulder 1 View Right,4100465,CDM,320,RC,73020,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,977.968,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3167.94,4819,
XR Shoulder 2 Views Left,4100466,CDM,320,RC,73030,HCPCS,OUTPATIENT,,,230,138,1-TC|2-LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,120.632,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,490.656,case rate,pays based on per visit rate,73.49,31.95,,109.656,Fee Schedule,31.95% of LA custom fee schedule,3168.94,4820,
Report,4100466,CDM,972,RC,73030,HCPCS,OUTPATIENT,,,30,18,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1035.184,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,228,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3169.94,4821,
XR Shoulder 2 Views Right,4100466,CDM,320,RC,73030,HCPCS,OUTPATIENT,,,230,138,1-TC|2-LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,21.584,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3170.94,4822,
Report,4100466,CDM,972,RC,73030,HCPCS,OUTPATIENT,,,30,18,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1035.184,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,21.584,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3171.94,4823,
Report,4100467,CDM,972,RC,70220,HCPCS,OUTPATIENT,,,38,22.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1035.184,other,Not separately reimbursable,24.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,398.848,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3172.94,4824,
XR Sinuses Paranasal Complete,4100467,CDM,320,RC,70220,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,14.896,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3173.94,4825,
Report,4100468,CDM,972,RC,70210,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1035.184,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,34.96,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3174.94,4826,
XR Sinuses Paranasal < 3 Views,4100468,CDM,320,RC,70210,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,18.544,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3175.94,4827,
Report,4100469,CDM,972,RC,70260,HCPCS,OUTPATIENT,,,52,31.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1035.184,other,Not separately reimbursable,27.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3176.94,4828,
XR Skull Complete,4100469,CDM,320,RC,70260,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,1035.184,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.52,case rate,pays based on per visit rate,116.3,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3177.94,4829,
Report,4100470,CDM,972,RC,70250,HCPCS,OUTPATIENT,,,38,22.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1093.968,other,Not separately reimbursable,24.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,2.128,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3178.94,4830,
XR Skull < 4 Views,4100470,CDM,320,RC,70250,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1168.096,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.824,case rate,pays based on per visit rate,73.49,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3179.94,4831,
Report,4100471,CDM,972,RC,74250,HCPCS,OUTPATIENT,,,72,43.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,20.248,other,Not separately reimbursable,,31.95,,1373.848,other,Not separately reimbursable,72,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.552,other,Not separately reimbursable,,,,18.4,other,Not separately reimbursable,3180.94,4832,
XR Small Bowel Series,4100471,CDM,320,RC,74250,HCPCS,OUTPATIENT,,,295,177,26,250.75,85,,200.6,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,103.69,35.15,,20.248,fee schedule,35.15% of LA custom fee schedule,94.25,31.95,,1375.128,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.432,case rate,pays based on per visit rate,94.25,31.95,,18.4,Fee Schedule,31.95% of LA custom fee schedule,3181.94,4833,
XR Small Bowel Series,4100471,CDM,320,RC,74250,HCPCS,OUTPATIENT,,,295,177,26,250.75,85,,200.6,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,103.69,35.15,,24.744,fee schedule,35.15% of LA custom fee schedule,94.25,31.95,,1405.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,241.68,case rate,pays based on per visit rate,94.25,31.95,,22.496,Fee Schedule,31.95% of LA custom fee schedule,3182.94,4834,
Report,4100471,CDM,972,RC,74250,HCPCS,OUTPATIENT,,,72,43.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,75.08,other,Not separately reimbursable,,31.95,,1405.8,other,Not separately reimbursable,72,100,,,fee schedule,100% of CMS physician fee schedule,,,,159.6,other,Not separately reimbursable,,,,68.248,other,Not separately reimbursable,3183.94,4835,
Report,4100472,CDM,972,RC,70360,HCPCS,OUTPATIENT,,,26,15.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,251.672,other,Not separately reimbursable,,31.95,,1405.8,other,Not separately reimbursable,19.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,697.376,other,Not separately reimbursable,,,,228.76,other,Not separately reimbursable,3184.94,4836,
XR Neck Soft Tissue,4100472,CDM,320,RC,70360,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,37.712,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1418.584,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,104.576,case rate,pays based on per visit rate,73.49,31.95,,34.272,Fee Schedule,31.95% of LA custom fee schedule,3185.94,4837,
Report,4100473,CDM,972,RC,72040,HCPCS,OUTPATIENT,,,35,21,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,33.704,other,Not separately reimbursable,,31.95,,1418.584,other,Not separately reimbursable,25.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,43.168,other,Not separately reimbursable,,,,30.632,other,Not separately reimbursable,3186.94,4838,
XR Spine Cervical 2 or 3 Views,4100473,CDM,320,RC,72040,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,83.52,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1418.584,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,31.92,case rate,pays based on per visit rate,73.49,31.95,,75.912,Fee Schedule,31.95% of LA custom fee schedule,3187.94,4839,
XR Spine Cervical 2 or 3 Views,4100473,CDM,320,RC,72040,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,476.912,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1418.584,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,31.616,case rate,pays based on per visit rate,73.49,31.95,,433.496,Fee Schedule,31.95% of LA custom fee schedule,3188.94,4840,
XR Spine Cervical 4 or 5 Views,4100474,CDM,320,RC,72050,HCPCS,OUTPATIENT,,,336,201.6,TC,285.6,85,,228.48,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,118.1,35.15,,382.152,fee schedule,35.15% of LA custom fee schedule,107.35,31.95,,1418.584,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.736,case rate,pays based on per visit rate,107.35,31.95,,347.36,Fee Schedule,31.95% of LA custom fee schedule,3189.94,4841,
Report,4100474,CDM,972,RC,72050,HCPCS,OUTPATIENT,,,41,24.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,63.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,129.448,other,Not separately reimbursable,,31.95,,1418.584,other,Not separately reimbursable,36.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.24,other,Not separately reimbursable,,,,117.664,other,Not separately reimbursable,3190.94,4842,
XR Spine Any Level Single View,4100475,CDM,320,RC,72020,HCPCS,OUTPATIENT,,,230,138,TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,348.688,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1482.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,18.24,case rate,pays based on per visit rate,73.49,31.95,,316.944,Fee Schedule,31.95% of LA custom fee schedule,3191.94,4843,
Report,4100475,CDM,972,RC,72020,HCPCS,OUTPATIENT,,,24,14.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,29.17,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,381.872,other,Not separately reimbursable,,31.95,,1526.952,other,Not separately reimbursable,14.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.864,other,Not separately reimbursable,,,,347.104,other,Not separately reimbursable,3192.94,4844,
Report,4100477,CDM,972,RC,71120,HCPCS,OUTPATIENT,,,31,18.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,393.68,other,Not separately reimbursable,,31.95,,1527.208,other,Not separately reimbursable,21.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,229.216,other,Not separately reimbursable,,,,357.84,other,Not separately reimbursable,3193.94,4845,
XR Sternum Minimum 2 Views,4100477,CDM,320,RC,71120,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,106.856,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1586,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,229.216,case rate,pays based on per visit rate,73.49,31.95,,97.128,Fee Schedule,31.95% of LA custom fee schedule,3194.94,4846,
Report,4100478,CDM,972,RC,72070,HCPCS,OUTPATIENT,,,35,21,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,91.952,other,Not separately reimbursable,,31.95,,1923.392,other,Not separately reimbursable,20.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.944,other,Not separately reimbursable,,,,83.584,other,Not separately reimbursable,3195.94,4847,
XR Spine Thoracic 2 Views,4100478,CDM,320,RC,72070,HCPCS,OUTPATIENT,,,175,105,26,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,131.6,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,191.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,2.736,case rate,pays based on per visit rate,55.91,31.95,,119.624,Fee Schedule,31.95% of LA custom fee schedule,3196.94,4848,
Report,4100479,CDM,972,RC,72072,HCPCS,OUTPATIENT,,,33,19.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,106.208,other,Not separately reimbursable,,31.95,,191.704,other,Not separately reimbursable,25.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,40.736,other,Not separately reimbursable,,,,96.544,other,Not separately reimbursable,3197.94,4849,
XR Spine Thoracic 3 Views,4100479,CDM,320,RC,72072,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,61.92,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,191.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,58.368,case rate,pays based on per visit rate,116.3,31.95,,56.28,Fee Schedule,31.95% of LA custom fee schedule,3198.94,4850,
Report,4100480,CDM,972,RC,72074,HCPCS,OUTPATIENT,,,33,19.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,176.032,other,Not separately reimbursable,,31.95,,191.704,other,Not separately reimbursable,29.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,341.696,other,Not separately reimbursable,,,,160.008,other,Not separately reimbursable,3199.94,4851,
XR Spine Thoracic Minimum 4 Views,4100480,CDM,320,RC,72074,HCPCS,OUTPATIENT,,,325,195,26,276.25,85,,221,Percent of total billed charges,85% of total billed charges,106.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,114.24,35.15,,194.032,fee schedule,35.15% of LA custom fee schedule,103.84,31.95,,191.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.824,case rate,pays based on per visit rate,103.84,31.95,,176.368,Fee Schedule,31.95% of LA custom fee schedule,3200.94,4852,
Report,4100481,CDM,972,RC,72080,HCPCS,OUTPATIENT,,,37,22.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,48.76,other,Not separately reimbursable,,31.95,,191.704,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.824,other,Not separately reimbursable,,,,44.32,other,Not separately reimbursable,3201.94,4853,
XR Spine Thoracolumbar 2 Views,4100481,CDM,320,RC,72080,HCPCS,OUTPATIENT,,,200,120,26,170,85,,136,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,55.76,fee schedule,35.15% of LA custom fee schedule,63.9,31.95,,191.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.168,case rate,pays based on per visit rate,63.9,31.95,,50.688,Fee Schedule,31.95% of LA custom fee schedule,3202.94,4854,
Report,4100482,CDM,972,RC,73590,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,303.696,other,Not separately reimbursable,,31.95,,191.704,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,33.744,other,Not separately reimbursable,,,,276.048,other,Not separately reimbursable,3203.94,4855,
XR Tibia/Fibula Bilateral Profee,4100482,CDM,972,RC,73590,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,84.36,other,Not separately reimbursable,,31.95,,191.704,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,26.448,other,Not separately reimbursable,,,,76.68,other,Not separately reimbursable,3204.94,4856,
Report,4100483,CDM,972,RC,73590,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,112.48,other,Not separately reimbursable,,31.95,,191.704,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.384,other,Not separately reimbursable,,,,102.24,other,Not separately reimbursable,3205.94,4857,
XR Tibia/Fibula Left,4100483,CDM,320,RC,73590,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,113.608,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,191.704,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.376,case rate,pays based on per visit rate,73.49,31.95,,103.264,Fee Schedule,31.95% of LA custom fee schedule,3206.94,4858,
XR Tibia/Fibula Bilateral,4100483,CDM,320,RC,73590,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,98.424,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,2323.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.376,case rate,pays based on per visit rate,73.49,31.95,,89.464,Fee Schedule,31.95% of LA custom fee schedule,3207.94,4859,
Report,4100484,CDM,972,RC,73590,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,85.2,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.376,other,Not separately reimbursable,,,,77.448,other,Not separately reimbursable,3208.94,4860,
XR Tibia/Fibula Right,4100484,CDM,320,RC,73590,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,88.576,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.376,case rate,pays based on per visit rate,73.49,31.95,,80.512,Fee Schedule,31.95% of LA custom fee schedule,3209.94,4861,
FMC XR Tibia/Fibula Right,4100484,CDM,320,RC,73590,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,20.496,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,16.112,case rate,pays based on per visit rate,73.49,31.95,,18.632,Fee Schedule,31.95% of LA custom fee schedule,3210.94,4862,
Report,4100485,CDM,972,RC,70330,HCPCS,OUTPATIENT,,,39,23.4,50,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,61.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.352,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,36.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.08,other,Not separately reimbursable,,,,13.952,other,Not separately reimbursable,3211.94,4863,
XR TMJ Open and Closed Bilateral,4100485,CDM,320,RC,70330,HCPCS,OUTPATIENT,,,200,120,50,170,85,,136,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,15.608,fee schedule,35.15% of LA custom fee schedule,63.9,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,16.112,case rate,pays based on per visit rate,63.9,31.95,,14.184,Fee Schedule,31.95% of LA custom fee schedule,3212.94,4864,
Report,4100486,CDM,972,RC,70328,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,15.608,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,14.184,other,Not separately reimbursable,3213.94,4865,
XR TMJ Open and Closed Left,4100486,CDM,320,RC,70328,HCPCS,OUTPATIENT,,,238,142.8,26,202.3,85,,161.84,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,83.66,35.15,,1546.6,fee schedule,35.15% of LA custom fee schedule,76.04,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,52.592,case rate,pays based on per visit rate,76.04,31.95,,1405.8,Fee Schedule,31.95% of LA custom fee schedule,3214.94,4866,
Report,4100487,CDM,972,RC,70328,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,759.24,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,690.12,other,Not separately reimbursable,3215.94,4867,
XR TMJ Open and Closed Right,4100487,CDM,320,RC,70328,HCPCS,OUTPATIENT,,,238,142.8,26,202.3,85,,161.84,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,83.66,35.15,,506.16,fee schedule,35.15% of LA custom fee schedule,76.04,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.384,case rate,pays based on per visit rate,76.04,31.95,,460.08,Fee Schedule,31.95% of LA custom fee schedule,3216.94,4868,
Report,4100488,CDM,972,RC,73660,HCPCS,OUTPATIENT,,,20,12,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,478.04,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.824,other,Not separately reimbursable,,,,434.52,other,Not separately reimbursable,3217.94,4869,
XR Toes Bilateral Profee,4100488,CDM,972,RC,73660,HCPCS,OUTPATIENT,,,20,12,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1546.6,other,Not separately reimbursable,,31.95,,230.04,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,6.08,other,Not separately reimbursable,,,,1405.8,other,Not separately reimbursable,3218.94,4870,
XR Toes Left,4100489,CDM,320,RC,73660,HCPCS,OUTPATIENT,,,230,138,1-LT|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,759.24,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,230.04,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,591.28,case rate,pays based on per visit rate,73.49,31.95,,690.12,Fee Schedule,31.95% of LA custom fee schedule,3219.94,4871,
Report,4100489,CDM,972,RC,73660,HCPCS,OUTPATIENT,,,20,12,1-LT|2-TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,506.16,other,Not separately reimbursable,,31.95,,843.48,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,591.28,other,Not separately reimbursable,,,,460.08,other,Not separately reimbursable,3220.94,4872,
XR Toes Bilateral,4100489,CDM,320,RC,73660,HCPCS,OUTPATIENT,,,230,138,1-LT|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,478.04,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,537.528,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,699.2,case rate,pays based on per visit rate,73.49,31.95,,434.52,Fee Schedule,31.95% of LA custom fee schedule,3221.94,4873,
XR Toes Right,4100490,CDM,320,RC,73660,HCPCS,OUTPATIENT,,,230,138,1-TC|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,1380.24,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,1380.24,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,56.24,case rate,pays based on per visit rate,73.49,31.95,,1728,Fee Schedule,31.95% of LA custom fee schedule,3222.94,4874,
Report,4100490,CDM,972,RC,73660,HCPCS,OUTPATIENT,,,20,12,1-TC|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,927.96,other,Not separately reimbursable,,31.95,,545.528,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,304,other,Not separately reimbursable,,,,843.48,other,Not separately reimbursable,3223.94,4875,
FMC XR Toes Right,4100490,CDM,320,RC,73660,HCPCS,OUTPATIENT,,,230,138,1-TC|2-RT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,1096.68,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,598.104,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.824,case rate,pays based on per visit rate,73.49,31.95,,996.84,Fee Schedule,31.95% of LA custom fee schedule,3224.94,4876,
XR UE Infant Min 2 Views Left,4100492,CDM,320,RC,73092,HCPCS,OUTPATIENT,,,364,218.4,1-TC|2-LT,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,674.88,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,715.68,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,38.608,case rate,pays based on per visit rate,116.3,31.95,,613.44,Fee Schedule,31.95% of LA custom fee schedule,3225.94,4877,
Report,4100492,CDM,972,RC,73092,HCPCS,OUTPATIENT,,,25,15,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,266.08,other,Not separately reimbursable,,31.95,,266.08,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.648,other,Not separately reimbursable,,,,333.12,other,Not separately reimbursable,3226.94,4878,
XR UE Infant Min 2 Views Right,4100492,CDM,320,RC,73092,HCPCS,OUTPATIENT,,,364,218.4,1-TC|2-LT,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,94.48,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,61.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,27.36,case rate,pays based on per visit rate,116.3,31.95,,85.88,Fee Schedule,31.95% of LA custom fee schedule,3227.94,4879,
Report,4100492,CDM,972,RC,73092,HCPCS,OUTPATIENT,,,25,15,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,75.08,other,Not separately reimbursable,,31.95,,149.528,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,148.96,other,Not separately reimbursable,,,,68.248,other,Not separately reimbursable,3228.94,4880,
Report,4100494,CDM,972,RC,73092,HCPCS,OUTPATIENT,,,25,15,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,75.08,other,Not separately reimbursable,,31.95,,172.528,other,Not separately reimbursable,21.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,161.12,other,Not separately reimbursable,,,,68.248,other,Not separately reimbursable,3229.94,4881,
XR Upper Extremity Infant,4100494,CDM,320,RC,73092,HCPCS,OUTPATIENT,,,364,218.4,26,309.4,85,,247.52,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.95,35.15,,75.08,fee schedule,35.15% of LA custom fee schedule,116.3,31.95,,19.92,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,164.16,case rate,pays based on per visit rate,116.3,31.95,,68.248,Fee Schedule,31.95% of LA custom fee schedule,3230.94,4882,
Report,4100495,CDM,972,RC,74240,HCPCS,OUTPATIENT,,,106,63.6,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,86.888,other,Not separately reimbursable,,31.95,,299.056,other,Not separately reimbursable,74.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,25.84,other,Not separately reimbursable,,,,78.984,other,Not separately reimbursable,3231.94,4883,
XR Upper GI,4100495,CDM,320,RC,74240,HCPCS,OUTPATIENT,,,605,363,26,514.25,85,,411.4,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,212.66,35.15,,86.888,fee schedule,35.15% of LA custom fee schedule,193.3,31.95,,48.056,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,4.864,case rate,pays based on per visit rate,193.3,31.95,,78.984,Fee Schedule,31.95% of LA custom fee schedule,3232.94,4884,
Report,4100496,CDM,972,RC,74246,HCPCS,OUTPATIENT,,,107,64.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,86.888,other,Not separately reimbursable,,31.95,,587.88,other,Not separately reimbursable,85.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,1.216,other,Not separately reimbursable,,,,78.984,other,Not separately reimbursable,3233.94,4885,
XR Upper GI w/ Air Contrast,4100496,CDM,320,RC,74246,HCPCS,OUTPATIENT,,,605,363,26,514.25,85,,411.4,Percent of total billed charges,85% of total billed charges,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,199.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,212.66,35.15,,416.736,fee schedule,35.15% of LA custom fee schedule,193.3,31.95,,37.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,19.76,case rate,pays based on per visit rate,193.3,31.95,,378.8,Fee Schedule,31.95% of LA custom fee schedule,3234.94,4886,
FMC XR URETHRA/BLADDER,4100501,CDM,320,RC,74450,HCPCS,OUTPATIENT,,,1031,618.6,TC,876.35,85,,701.08,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.4,35.15,,94.48,fee schedule,35.15% of LA custom fee schedule,329.4,31.95,,37.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,60.8,case rate,pays based on per visit rate,329.4,31.95,,85.88,Fee Schedule,31.95% of LA custom fee schedule,3235.94,4887,
Report,4100502,CDM,972,RC,74455,HCPCS,OUTPATIENT,,,49,29.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,112.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,75.08,other,Not separately reimbursable,,31.95,,290.704,other,Not separately reimbursable,49,100,,,fee schedule,100% of CMS physician fee schedule,,,,158.08,other,Not separately reimbursable,,,,68.248,other,Not separately reimbursable,3236.94,4888,
XR Urethrocystography Retrograde,4100502,CDM,320,RC,74455,HCPCS,OUTPATIENT,,,1030,618,26,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.05,35.15,,535.968,fee schedule,35.15% of LA custom fee schedule,329.09,31.95,,77.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,6.688,case rate,pays based on per visit rate,329.09,31.95,,487.176,Fee Schedule,31.95% of LA custom fee schedule,3237.94,4889,
FMC FLUOROGUIDE FOR VEIN D,4100502,CDM,320,RC,77001,HCPCS,OUTPATIENT,,,250,150,26,212.5,85,,170,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,80.144,fee schedule,35.15% of LA custom fee schedule,79.88,31.95,,109.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,152,case rate,pays based on per visit rate,79.88,31.95,,72.848,Fee Schedule,31.95% of LA custom fee schedule,3238.94,4890,
Report,4100503,CDM,972,RC,73100,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,111.64,other,Not separately reimbursable,,31.95,,109.912,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,4.256,other,Not separately reimbursable,,,,101.472,other,Not separately reimbursable,3239.94,4891,
FMC LEXISCAN 0.1MG INJ,4100503,CDM,250,RC,J2785,HCPCS,OUTPATIENT,,,166,99.6,26,141.1,85,,112.88,Percent of total billed charges,85% of total billed charges,52.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,52.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,58.35,35.15,,28.68,fee schedule,35.15% of LA custom fee schedule,53.04,31.95,,109.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,63.08,38,,9.728,percent of total billed charges,38% of total billed charges,53.04,31.95,,26.072,Fee Schedule,31.95% of LA custom fee schedule,3240.94,4892,
XR Wrist 2 Views Bilateral Profee,4100503,CDM,972,RC,73100,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,222.712,other,Not separately reimbursable,,31.95,,109.912,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.776,other,Not separately reimbursable,,,,202.432,other,Not separately reimbursable,3241.94,4893,
Report,4100504,CDM,972,RC,73100,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,209.216,other,Not separately reimbursable,,31.95,,109.912,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.472,other,Not separately reimbursable,,,,190.168,other,Not separately reimbursable,3242.94,4894,
XR Wrist 2 Views Left,4100504,CDM,320,RC,73100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,167.032,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,109.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,1.216,case rate,pays based on per visit rate,73.49,31.95,,151.824,Fee Schedule,31.95% of LA custom fee schedule,3243.94,4895,
XR Wrist 2 Views Bilateral,4100504,CDM,320,RC,73100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,167.032,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,109.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,9.12,case rate,pays based on per visit rate,73.49,31.95,,151.824,Fee Schedule,31.95% of LA custom fee schedule,3244.94,4896,
Report,4100505,CDM,972,RC,73100,HCPCS,OUTPATIENT,,,27,16.2,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1518.48,other,Not separately reimbursable,,31.95,,109.912,other,Not separately reimbursable,22.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.472,other,Not separately reimbursable,,,,1380.24,other,Not separately reimbursable,3245.94,4897,
XR Wrist 2 Views Right,4100505,CDM,320,RC,73100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,927.96,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,109.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.472,case rate,pays based on per visit rate,73.49,31.95,,843.48,Fee Schedule,31.95% of LA custom fee schedule,3246.94,4898,
FMC XR Wrist 2 Views Right,4100505,CDM,320,RC,73100,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,1096.68,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,109.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,12.16,case rate,pays based on per visit rate,73.49,31.95,,996.84,Fee Schedule,31.95% of LA custom fee schedule,3247.94,4899,
Report,4100506,CDM,972,RC,73110,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,145.944,other,Not separately reimbursable,,31.95,,109.912,other,Not separately reimbursable,28,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.6,other,Not separately reimbursable,,,,132.656,other,Not separately reimbursable,3248.94,4900,
FMC NM TC 99 APCITIDE; PER VI,4100506,CDM,343,RC,A9504,HCPCS,OUTPATIENT,,,1700,1020,26,1445,85,,1156,Percent of total billed charges,85% of total billed charges,850,50,,680,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,850,50,,680,percent of total billed charges,50% of total billed charges,597.55,35.15,,1124.8,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,166.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,34.352,other,Not separately reimbursable,543.15,31.95,,1022.4,percent of total billed charges,31.95% of total billed charges,3249.94,4901,
XR Wrist Complete Bilateral Profee,4100506,CDM,972,RC,73110,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,843.6,other,Not separately reimbursable,,31.95,,279.976,other,Not separately reimbursable,28,100,,,fee schedule,100% of CMS physician fee schedule,,,,84.512,other,Not separately reimbursable,,,,766.8,other,Not separately reimbursable,3250.94,4902,
Report,4100507,CDM,972,RC,73110,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,89.424,other,Not separately reimbursable,,31.95,,364.008,other,Not separately reimbursable,28,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.24,other,Not separately reimbursable,,,,81.28,other,Not separately reimbursable,3251.94,4903,
XR Wrist Complete Left,4100507,CDM,320,RC,73110,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,843.6,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,9.712,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,51.68,case rate,pays based on per visit rate,73.49,31.95,,766.8,Fee Schedule,31.95% of LA custom fee schedule,3252.94,4904,
XR Wrist Complete Bilateral,4100507,CDM,320,RC,73110,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,1406,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,10.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.376,case rate,pays based on per visit rate,73.49,31.95,,1278,Fee Schedule,31.95% of LA custom fee schedule,3253.94,4905,
FMC NM TC MDP PER 30 MCI,4100507,CDM,343,RC,A9503,HCPCS,OUTPATIENT,,,100,60,26,85,85,,68,Percent of total billed charges,85% of total billed charges,16.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.15,35.15,,843.6,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,16.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,12.16,other,Not separately reimbursable,31.95,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,3254.94,4906,
Report,4100508,CDM,972,RC,73110,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,843.6,other,Not separately reimbursable,,31.95,,22.752,other,Not separately reimbursable,28,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.8,other,Not separately reimbursable,,,,766.8,other,Not separately reimbursable,3255.94,4907,
XR Wrist Complete Right,4100508,CDM,320,RC,73110,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,89.424,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,3.32,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.952,case rate,pays based on per visit rate,73.49,31.95,,81.28,Fee Schedule,31.95% of LA custom fee schedule,3256.94,4908,
FMC OPTIRAY CONTRAST,4100508,CDM,254,RC,Q9965,HCPCS,OUTPATIENT,,,5,3,26,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,1.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1.6,31.95,,108.544,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,30.096,percent of total billed charges,38% of total billed charges,2,40,,98.664,percent of total billed charges,40% of total billed charges,3257.94,4909,
FMC XR Wrist Complete Right,4100508,CDM,320,RC,73110,HCPCS,OUTPATIENT,,,230,138,26,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,1265.4,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,8.688,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.8,case rate,pays based on per visit rate,73.49,31.95,,1150.2,Fee Schedule,31.95% of LA custom fee schedule,3258.94,4910,
Report,4100509,CDM,972,RC,77072,HCPCS,OUTPATIENT,,,29,17.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,843.6,other,Not separately reimbursable,,31.95,,8.688,other,Not separately reimbursable,14.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.8,other,Not separately reimbursable,,,,766.8,other,Not separately reimbursable,3259.94,4911,
XR Bone Age Studies,4100509,CDM,320,RC,77072,HCPCS,OUTPATIENT,,,175,105,26,148.75,85,,119,Percent of total billed charges,85% of total billed charges,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.51,35.15,,913.904,fee schedule,35.15% of LA custom fee schedule,55.91,31.95,,8.688,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.8,case rate,pays based on per visit rate,55.91,31.95,,830.704,Fee Schedule,31.95% of LA custom fee schedule,3260.94,4912,
MA Mammogram Routine Screening Right.,4100511,CDM,403,RC,77067,HCPCS,OUTPATIENT,,,540,324,1-52|2-TC|3-RT,459,85,,367.2,Percent of total billed charges,85% of total billed charges,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.81,35.15,,111.64,fee schedule,35.15% of LA custom fee schedule,172.53,31.95,,27.096,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,5.168,case rate,pays based on per visit rate,172.53,31.95,,101.472,Fee Schedule,31.95% of LA custom fee schedule,3261.94,4913,
Report,4100511,CDM,972,RC,77067,HCPCS,OUTPATIENT,,,105,63,1-52|2-TC|3-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1265.4,other,Not separately reimbursable,,31.95,,30.16,other,Not separately reimbursable,81.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,5.472,other,Not separately reimbursable,,,,1150.2,other,Not separately reimbursable,3262.94,4914,
MA Mammo Screening 3D Right,4100511,CDM,403,RC,77067,HCPCS,OUTPATIENT,,,540,324,1-52|2-TC|3-RT,459,85,,367.2,Percent of total billed charges,85% of total billed charges,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,189.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.81,35.15,,913.904,fee schedule,35.15% of LA custom fee schedule,172.53,31.95,,30.16,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,31.92,case rate,pays based on per visit rate,172.53,31.95,,830.704,Fee Schedule,31.95% of LA custom fee schedule,3263.94,4915,
Report,4100511,CDM,972,RC,77067,HCPCS,OUTPATIENT,,,105,63,1-52|2-TC|3-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,421.8,other,Not separately reimbursable,,31.95,,31.952,other,Not separately reimbursable,81.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,30.4,other,Not separately reimbursable,,,,383.4,other,Not separately reimbursable,3264.94,4916,
XR Spine Entire Min 6 Views,4100512,CDM,320,RC,72084,HCPCS,OUTPATIENT,,,768,460.8,TC,652.8,85,,522.24,Percent of total billed charges,85% of total billed charges,148.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,148.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,269.95,35.15,,37.064,fee schedule,35.15% of LA custom fee schedule,245.38,31.95,,37.064,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,7.296,case rate,pays based on per visit rate,245.38,31.95,,46.4,Fee Schedule,31.95% of LA custom fee schedule,3265.94,4917,
Report,4100512,CDM,972,RC,72084,HCPCS,OUTPATIENT,,,61,36.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,456.384,other,Not separately reimbursable,,31.95,,370.624,other,Not separately reimbursable,61,100,,,fee schedule,100% of CMS physician fee schedule,,,,45.6,other,Not separately reimbursable,,,,414.84,other,Not separately reimbursable,3266.94,4918,
Report,4100513,CDM,972,RC,74455,HCPCS,OUTPATIENT,,,49,29.4,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,112.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1012.32,other,Not separately reimbursable,,31.95,,29.392,other,Not separately reimbursable,49,100,,,fee schedule,100% of CMS physician fee schedule,,,,118.56,other,Not separately reimbursable,,,,920.16,other,Not separately reimbursable,3267.94,4919,
XR Urethrocystography Voiding,4100513,CDM,320,RC,74455,HCPCS,OUTPATIENT,,,1030,618,26,875.5,85,,700.4,Percent of total billed charges,85% of total billed charges,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,347.59,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,362.05,35.15,,44.712,fee schedule,35.15% of LA custom fee schedule,329.09,31.95,,130.36,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,18.24,case rate,pays based on per visit rate,329.09,31.95,,40.64,Fee Schedule,31.95% of LA custom fee schedule,3268.94,4920,
Report,4100514,CDM,972,RC,70120,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,69.736,other,Not separately reimbursable,,31.95,,35.416,other,Not separately reimbursable,26.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,42.56,other,Not separately reimbursable,,,,63.392,other,Not separately reimbursable,3269.94,4921,
XR Mastoids < 3 Views Bilateral Profee,4100514,CDM,972,RC,70120,HCPCS,OUTPATIENT,,,28,16.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,32.616,other,Not separately reimbursable,,31.95,,36.888,other,Not separately reimbursable,26.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,29.648,other,Not separately reimbursable,3270.94,4922,
XR Spine Cervical 6 or More Views,4100515,CDM,320,RC,72052,HCPCS,OUTPATIENT,,,403,241.8,TC,342.55,85,,274.04,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,141.65,35.15,,1356.224,fee schedule,35.15% of LA custom fee schedule,128.76,31.95,,36.888,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,5.472,case rate,pays based on per visit rate,128.76,31.95,,1232.76,Fee Schedule,31.95% of LA custom fee schedule,3271.94,4923,
Report,4100515,CDM,972,RC,72052,HCPCS,OUTPATIENT,,,55,33,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1945.344,other,Not separately reimbursable,,31.95,,37.384,other,Not separately reimbursable,42.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,20.976,other,Not separately reimbursable,,,,1768.24,other,Not separately reimbursable,3272.94,4924,
XR Spine Entire 1 View,4100516,CDM,320,RC,72081,HCPCS,OUTPATIENT,,,244,146.4,TC,207.4,85,,165.92,Percent of total billed charges,85% of total billed charges,62.69,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,62.69,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,85.77,35.15,,1012.32,fee schedule,35.15% of LA custom fee schedule,77.96,31.95,,9.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,9.12,case rate,pays based on per visit rate,77.96,31.95,,920.16,Fee Schedule,31.95% of LA custom fee schedule,3273.94,4925,
Report,4100516,CDM,972,RC,72081,HCPCS,OUTPATIENT,,,41,24.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,51.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,506.16,other,Not separately reimbursable,,31.95,,19.936,other,Not separately reimbursable,26.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,66.88,other,Not separately reimbursable,,,,460.08,other,Not separately reimbursable,3274.94,4926,
XR Spine Entire 2-3 Views,4100517,CDM,320,RC,72082,HCPCS,OUTPATIENT,,,403,241.8,TC,342.55,85,,274.04,Percent of total billed charges,85% of total billed charges,113.95,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,113.95,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,141.65,35.15,,463.984,fee schedule,35.15% of LA custom fee schedule,128.76,31.95,,59.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,104.576,case rate,pays based on per visit rate,128.76,31.95,,421.744,Fee Schedule,31.95% of LA custom fee schedule,3275.94,4927,
Report,4100517,CDM,972,RC,72082,HCPCS,OUTPATIENT,,,49,29.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,81.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,179.968,other,Not separately reimbursable,,31.95,,9.192,other,Not separately reimbursable,48.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,109.44,other,Not separately reimbursable,,,,163.584,other,Not separately reimbursable,3276.94,4928,
Report,4100518,CDM,972,RC,72083,HCPCS,OUTPATIENT,,,53,31.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,108.544,other,Not separately reimbursable,,31.95,,109.656,other,Not separately reimbursable,53,100,,,fee schedule,100% of CMS physician fee schedule,,,,172.672,other,Not separately reimbursable,,,,98.664,other,Not separately reimbursable,3277.94,4929,
Report,4100519,CDM,972,RC,73702,HCPCS,OUTPATIENT,,,183,109.8,1-26|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,151.568,other,Not separately reimbursable,,31.95,,11.168,other,Not separately reimbursable,126.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,259.008,other,Not separately reimbursable,,,,137.768,other,Not separately reimbursable,3278.94,4930,
CT Lower Extremity w/+w/o Contrast Left,4100519,CDM,350,RC,73702,HCPCS,OUTPATIENT,,,1355,813,1-26|2-LT,1151.75,85,,921.4,Percent of total billed charges,85% of total billed charges,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,102.072,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,149.528,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,345.344,case rate,pays based on per visit rate,432.92,31.95,,92.784,Fee Schedule,31.95% of LA custom fee schedule,3279.94,4931,
Report,4100520,CDM,972,RC,73702,HCPCS,OUTPATIENT,,,183,109.8,1-26|2-RT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,85.488,other,Not separately reimbursable,,31.95,,187.408,other,Not separately reimbursable,126.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,518.016,other,Not separately reimbursable,,,,77.704,other,Not separately reimbursable,3280.94,4932,
CT Lower Extremity w/+w/o Contrast Right,4100520,CDM,350,RC,73702,HCPCS,OUTPATIENT,,,1355,813,1-26|2-RT,1151.75,85,,921.4,Percent of total billed charges,85% of total billed charges,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,857.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,476.28,35.15,,980.824,fee schedule,35.15% of LA custom fee schedule,432.92,31.95,,13.288,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,518.016,case rate,pays based on per visit rate,432.92,31.95,,891.536,Fee Schedule,31.95% of LA custom fee schedule,3281.94,4933,
Report,4100521,CDM,972,RC,72125,HCPCS,OUTPATIENT,,,160,96,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,980.824,other,Not separately reimbursable,,31.95,,18.744,other,Not separately reimbursable,76.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,130.72,other,Not separately reimbursable,,,,891.536,other,Not separately reimbursable,3282.94,4934,
CT Spine Cervical w/o Contrast,4100521,CDM,350,RC,72125,HCPCS,OUTPATIENT,,,925,555,26,786.25,85,,629,Percent of total billed charges,85% of total billed charges,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,586.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,325.14,35.15,,759.24,fee schedule,35.15% of LA custom fee schedule,295.54,31.95,,95.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,11.248,case rate,pays based on per visit rate,295.54,31.95,,690.12,Fee Schedule,31.95% of LA custom fee schedule,3283.94,4935,
MRV Head w/o Contrast,4100522,CDM,615,RC,70544,HCPCS,OUTPATIENT,,,1400,840,TC,1190,85,,952,Percent of total billed charges,85% of total billed charges,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1089.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,447.3,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,518.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,900,100,,8.512,case rate,pays based on per visit rate,560,40,,498.424,percent of total billed charges,40% of total billed charges,3284.94,4936,
Report,4100522,CDM,972,RC,70544,HCPCS,OUTPATIENT,,,180,108,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,346.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,98.424,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,145.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,3.8,other,Not separately reimbursable,,,,89.464,other,Not separately reimbursable,3285.94,4937,
XR Spine Entire 4-5 Views,4100524,CDM,320,RC,72083,HCPCS,OUTPATIENT,,,768,460.8,TC,652.8,85,,522.24,Percent of total billed charges,85% of total billed charges,123.69,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,123.69,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,269.95,35.15,,99.824,fee schedule,35.15% of LA custom fee schedule,245.38,31.95,,3.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,88.16,case rate,pays based on per visit rate,245.38,31.95,,90.736,Fee Schedule,31.95% of LA custom fee schedule,3286.94,4938,
Report,4100525,CDM,972,RC,47000,HCPCS,OUTPATIENT,,,1020,612,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,445.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,98.424,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,82.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,41.952,other,Not separately reimbursable,,,,89.464,other,Not separately reimbursable,3287.94,4939,
CT Biopsy Liver,4100525,CDM,360,RC,47000,HCPCS,OUTPATIENT,,,3031,1818.6,26,2576.35,85,,2061.08,Percent of total billed charges,85% of total billed charges,1502.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1502.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,968.4,31.95,,168.72,percent of total billed charges,31.95% of total billed charges,968.4,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,10.64,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1212.4,40,,153.36,percent of total billed charges,40% of total billed charges,3288.94,4940,
Report,4100526,CDM,972,RC,77073,HCPCS,OUTPATIENT,,,40,24,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,175.752,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,28.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,7.904,other,Not separately reimbursable,,,,159.752,other,Not separately reimbursable,3289.94,4941,
XR Bone Length Studies Scanograms,4100526,CDM,320,RC,77073,HCPCS,OUTPATIENT,,,335,201,26,284.75,85,,227.8,Percent of total billed charges,85% of total billed charges,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,168.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,117.75,35.15,,84.36,fee schedule,35.15% of LA custom fee schedule,107.03,31.95,,3.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,15.504,case rate,pays based on per visit rate,107.03,31.95,,76.68,Fee Schedule,31.95% of LA custom fee schedule,3290.94,4942,
FMC Dotarem 1 ML,4100527,CDM,270,RC,A9575,HCPCS,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,0.18,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.18,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,5.98,35.15,,165.912,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,19.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,3.8,percent of total billed charges,38% of total billed charges,5.43,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,3291.94,4943,
NM HIDA Scan w/o CCK,4100529,CDM,341,RC,78226,HCPCS,OUTPATIENT,,,1120,672,TC,952,85,,761.6,Percent of total billed charges,85% of total billed charges,845.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,845.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,393.68,35.15,,28.12,fee schedule,35.15% of LA custom fee schedule,357.84,31.95,,19.312,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,6.08,case rate,pays based on per visit rate,357.84,31.95,,25.56,Fee Schedule,31.95% of LA custom fee schedule,3292.94,4944,
Report,4100529,CDM,972,RC,78226,HCPCS,OUTPATIENT,,,105,63,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,416.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,106.856,other,Not separately reimbursable,,31.95,,19.92,other,Not separately reimbursable,105,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.856,other,Not separately reimbursable,,,,97.128,other,Not separately reimbursable,3293.94,4945,
CN NM HIDA SCAN WO CCK,4100529,CDM,341,RC,78226,HCPCS,OUTPATIENT,,,1120,672,TC,952,85,,761.6,Percent of total billed charges,85% of total billed charges,845.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,845.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,393.68,35.15,,196.84,fee schedule,35.15% of LA custom fee schedule,357.84,31.95,,44.088,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,750,100,,11.856,case rate,pays based on per visit rate,357.84,31.95,,178.92,Fee Schedule,31.95% of LA custom fee schedule,3294.94,4946,
PROFEE,4100529,CDM,972,RC,78226,HCPCS,OUTPATIENT,,,105,63,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,416.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.032,other,Not separately reimbursable,,31.95,,9.344,other,Not separately reimbursable,105,100,,,fee schedule,100% of CMS physician fee schedule,,,,11.856,other,Not separately reimbursable,,,,14.568,other,Not separately reimbursable,3295.94,4947,
XR Hips Bil w/ Pelvis Min 5 Views,4100530,CDM,320,RC,73523,HCPCS,OUTPATIENT,,,768,460.8,TC,652.8,85,,522.24,Percent of total billed charges,85% of total billed charges,99.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,99.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,269.95,35.15,,548.344,fee schedule,35.15% of LA custom fee schedule,245.38,31.95,,11.96,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,13.376,case rate,pays based on per visit rate,245.38,31.95,,498.424,Fee Schedule,31.95% of LA custom fee schedule,3296.94,4948,
Report,4100530,CDM,972,RC,73523,HCPCS,OUTPATIENT,,,49,29.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,253.08,other,Not separately reimbursable,,31.95,,14.272,other,Not separately reimbursable,41.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,41.952,other,Not separately reimbursable,,,,230.04,other,Not separately reimbursable,3297.94,4949,
XR Hip 2-3 Views Lt w/ Pelvis,4100532,CDM,320,RC,73502,HCPCS,OUTPATIENT,,,244,146.4,1-TC|2-LT,207.4,85,,165.92,Percent of total billed charges,85% of total billed charges,74.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,85.77,35.15,,506.16,fee schedule,35.15% of LA custom fee schedule,77.96,31.95,,14.952,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,29.184,case rate,pays based on per visit rate,77.96,31.95,,460.08,Fee Schedule,31.95% of LA custom fee schedule,3298.94,4950,
Report,4100532,CDM,972,RC,73502,HCPCS,OUTPATIENT,,,34,20.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,463.984,other,Not separately reimbursable,,31.95,,4.984,other,Not separately reimbursable,32.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,26.752,other,Not separately reimbursable,,,,421.744,other,Not separately reimbursable,3299.94,4951,
XR Hip 2-3 Views Rt w/ Pelvis,4100532,CDM,320,RC,73502,HCPCS,OUTPATIENT,,,244,146.4,1-TC|2-LT,207.4,85,,165.92,Percent of total billed charges,85% of total billed charges,74.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,85.77,35.15,,253.08,fee schedule,35.15% of LA custom fee schedule,77.96,31.95,,5.984,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,176.928,case rate,pays based on per visit rate,77.96,31.95,,230.04,Fee Schedule,31.95% of LA custom fee schedule,3300.94,4952,
Report,4100532,CDM,972,RC,73502,HCPCS,OUTPATIENT,,,34,20.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,253.08,other,Not separately reimbursable,,31.95,,7.408,other,Not separately reimbursable,32.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,176.928,other,Not separately reimbursable,,,,230.04,other,Not separately reimbursable,3301.94,4953,
XR Hip Min 4 Views Lt w/ Pelvis,4100534,CDM,320,RC,73503,HCPCS,OUTPATIENT,,,403,241.8,1-TC|2-LT,342.55,85,,274.04,Percent of total billed charges,85% of total billed charges,91.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,141.65,35.15,,122.688,fee schedule,35.15% of LA custom fee schedule,128.76,31.95,,122.688,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.8,case rate,pays based on per visit rate,128.76,31.95,,153.6,Fee Schedule,31.95% of LA custom fee schedule,3302.94,4954,
Report,4100534,CDM,972,RC,73503,HCPCS,OUTPATIENT,,,44,26.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,67.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,759.24,other,Not separately reimbursable,,31.95,,7.408,other,Not separately reimbursable,41.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,334.4,other,Not separately reimbursable,,,,690.12,other,Not separately reimbursable,3303.94,4955,
XR Hip Min 4 Views Rt w/ Pelvis,4100534,CDM,320,RC,73503,HCPCS,OUTPATIENT,,,403,241.8,1-TC|2-LT,342.55,85,,274.04,Percent of total billed charges,85% of total billed charges,91.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,141.65,35.15,,253.08,fee schedule,35.15% of LA custom fee schedule,128.76,31.95,,9.976,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,7.904,case rate,pays based on per visit rate,128.76,31.95,,230.04,Fee Schedule,31.95% of LA custom fee schedule,3304.94,4956,
Report,4100534,CDM,972,RC,73503,HCPCS,OUTPATIENT,,,44,26.4,1-TC|2-LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,67.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,98.424,other,Not separately reimbursable,,31.95,,14.376,other,Not separately reimbursable,41.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,55.024,other,Not separately reimbursable,,,,89.464,other,Not separately reimbursable,3305.94,4957,
XR Hips Bil w/ Pelvis 2 Views,4100536,CDM,320,RC,73521,HCPCS,OUTPATIENT,,,403,241.8,TC,342.55,85,,274.04,Percent of total billed charges,85% of total billed charges,69.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,141.65,35.15,,16.032,fee schedule,35.15% of LA custom fee schedule,128.76,31.95,,83.792,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,4.56,case rate,pays based on per visit rate,128.76,31.95,,14.568,Fee Schedule,31.95% of LA custom fee schedule,3306.94,4958,
Report,4100536,CDM,972,RC,73521,HCPCS,OUTPATIENT,,,35,21,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,16.032,other,Not separately reimbursable,,31.95,,49.504,other,Not separately reimbursable,26.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,72.96,other,Not separately reimbursable,,,,14.568,other,Not separately reimbursable,3307.94,4959,
XR Hips Bil w/ Pelvis 3-4 Views,4100538,CDM,320,RC,73522,HCPCS,OUTPATIENT,,,403,241.8,TC,342.55,85,,274.04,Percent of total billed charges,85% of total billed charges,83.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,83.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,141.65,35.15,,590.52,fee schedule,35.15% of LA custom fee schedule,128.76,31.95,,62.304,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,3.8,case rate,pays based on per visit rate,128.76,31.95,,536.76,Fee Schedule,31.95% of LA custom fee schedule,3308.94,4960,
Report,4100538,CDM,972,RC,73522,HCPCS,OUTPATIENT,,,46,27.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,62.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,548.344,other,Not separately reimbursable,,31.95,,599.104,other,Not separately reimbursable,35.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,66.88,other,Not separately reimbursable,,,,498.424,other,Not separately reimbursable,3309.94,4961,
CT Biopsy Bone Trocar/Needle Superficial,4100539,CDM,360,RC,20220,HCPCS,OUTPATIENT,,,3768,2260.8,TC,3202.8,85,,2562.24,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1203.88,31.95,,467.352,percent of total billed charges,31.95% of total billed charges,1203.88,31.95,,1046.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,5.776,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1507.2,40,,424.808,percent of total billed charges,40% of total billed charges,3310.94,4962,
Report,4100539,CDM,960,RC,20220,HCPCS,OUTPATIENT,,,477,286.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,247.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,411.68,other,Not separately reimbursable,,31.95,,6.176,other,Not separately reimbursable,82.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,13.68,other,Not separately reimbursable,,,,374.2,other,Not separately reimbursable,3311.94,4963,
CT Biopsy Bone Trocar/Needle Superficial,4100539,CDM,360,RC,77012,HCPCS,OUTPATIENT,,,1185,711,TC,1007.25,85,,805.8,Percent of total billed charges,85% of total billed charges,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,378.61,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,378.61,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,18.24,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,474,40,,1.92,percent of total billed charges,40% of total billed charges,3312.94,4964,
CT Biopsy Bone Trocar/Needle Superficial ProFee,4100539,CDM,960,RC,77012,HCPCS,OUTPATIENT,,,172,103.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1.536,other,Not separately reimbursable,,31.95,,1.536,other,Not separately reimbursable,62.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.24,other,Not separately reimbursable,,,,1.92,other,Not separately reimbursable,3313.94,4965,
CT Biopsy Bone Deep,4100540,CDM,360,RC,20225,HCPCS,OUTPATIENT,,,5658,3394.8,TC,4809.3,85,,3847.44,Percent of total billed charges,85% of total billed charges,1737.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1807.73,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,1807.73,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,18.24,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,2263.2,40,,22.4,percent of total billed charges,40% of total billed charges,3314.94,4966,
Report,4100540,CDM,960,RC,20225,HCPCS,OUTPATIENT,,,1456,873.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,743.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,99.176,other,Not separately reimbursable,,31.95,,99.176,other,Not separately reimbursable,121.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.24,other,Not separately reimbursable,,,,124.16,other,Not separately reimbursable,3315.94,4967,
CT Biopsy Bone Deep,4100540,CDM,360,RC,20225,HCPCS,OUTPATIENT,,,5658,3394.8,TC,4809.3,85,,3847.44,Percent of total billed charges,85% of total billed charges,1737.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1807.73,31.95,,70.304,percent of total billed charges,31.95% of total billed charges,1807.73,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,18.24,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,2263.2,40,,63.904,percent of total billed charges,40% of total billed charges,3316.94,4968,
CT Biopsy Bone Deep ProFee,4100540,CDM,960,RC,77012,HCPCS,OUTPATIENT,,,172,103.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,33.232,other,Not separately reimbursable,,31.95,,33.232,other,Not separately reimbursable,62.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.24,other,Not separately reimbursable,,,,41.6,other,Not separately reimbursable,3317.94,4969,
CT Guided Biopsy Pleura Perc Ndl,4100541,CDM,360,RC,32400,HCPCS,OUTPATIENT,,,3768,2260.8,TC,3202.8,85,,2562.24,Percent of total billed charges,85% of total billed charges,1502.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1502.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1203.88,31.95,,444.296,percent of total billed charges,31.95% of total billed charges,1203.88,31.95,,3.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,3.8,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1507.2,40,,403.848,percent of total billed charges,40% of total billed charges,3318.94,4970,
Report,4100541,CDM,960,RC,32400,HCPCS,OUTPATIENT,,,439,263.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,230.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,463.984,other,Not separately reimbursable,,31.95,,7,other,Not separately reimbursable,79.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.12,other,Not separately reimbursable,,,,421.744,other,Not separately reimbursable,3319.94,4971,
CT Guided Biopsy Pleura Perc Ndl,4100541,CDM,360,RC,77012,HCPCS,OUTPATIENT,,,1185,711,TC,1007.25,85,,805.8,Percent of total billed charges,85% of total billed charges,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,378.61,31.95,,589.112,percent of total billed charges,31.95% of total billed charges,378.61,31.95,,9.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,9.728,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,474,40,,535.48,percent of total billed charges,40% of total billed charges,3320.94,4972,
CT Guided Biopsy Pleura Perc Ndl ProFee,4100541,CDM,960,RC,77012,HCPCS,OUTPATIENT,,,172,103.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,463.984,other,Not separately reimbursable,,31.95,,3122.2,other,Not separately reimbursable,62.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,22.8,other,Not separately reimbursable,,,,421.744,other,Not separately reimbursable,3321.94,4973,
US Guided Biopsy Pleura Perc Ndl,4100542,CDM,360,RC,32400,HCPCS,OUTPATIENT,,,3768,2260.8,TC,3202.8,85,,2562.24,Percent of total billed charges,85% of total billed charges,1502.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1502.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1203.88,31.95,,168.72,percent of total billed charges,31.95% of total billed charges,1203.88,31.95,,1834.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,25.536,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1507.2,40,,153.36,percent of total billed charges,40% of total billed charges,3322.94,4974,
Report,4100542,CDM,960,RC,32400,HCPCS,OUTPATIENT,,,439,263.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,230.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,76.68,other,Not separately reimbursable,,31.95,,76.68,other,Not separately reimbursable,79.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,36.48,other,Not separately reimbursable,,,,96,other,Not separately reimbursable,3323.94,4975,
US Guided Biopsy Pleura Perc Ndl,4100542,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,400,240,TC,340,85,,272,Percent of total billed charges,85% of total billed charges,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,95.848,fee schedule,35.15% of LA custom fee schedule,127.8,31.95,,95.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,44.08,case rate,pays based on per visit rate,127.8,31.95,,120,Fee Schedule,31.95% of LA custom fee schedule,3324.94,4976,
US Guided Biopsy Pleura Perc Ndl ProFee,4100542,CDM,960,RC,76942,HCPCS,OUTPATIENT,,,250,150,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1012.32,other,Not separately reimbursable,,31.95,,3.064,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,40.128,other,Not separately reimbursable,,,,920.16,other,Not separately reimbursable,3325.94,4977,
CT Guided Lung Biopsy,4100543,CDM,360,RC,32408,HCPCS,OUTPATIENT,,,3768,2260.8,TC,3202.8,85,,2562.24,Percent of total billed charges,85% of total billed charges,2507.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2507.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1203.88,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,1203.88,31.95,,3.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,4.864,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1507.2,40,,460.08,percent of total billed charges,40% of total billed charges,3326.94,4978,
Report,4100543,CDM,960,RC,32408,HCPCS,OUTPATIENT,,,1249,749.4,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1416.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,44.712,other,Not separately reimbursable,,31.95,,5.072,other,Not separately reimbursable,143.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,41.952,other,Not separately reimbursable,,,,40.64,other,Not separately reimbursable,3327.94,4979,
CT Guided Lung Biopsy,4100543,CDM,360,RC,77012,HCPCS,OUTPATIENT,,,1185,711,TC,1007.25,85,,805.8,Percent of total billed charges,85% of total billed charges,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,378.61,31.95,,78.736,percent of total billed charges,31.95% of total billed charges,378.61,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,120.08,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,474,40,,71.568,percent of total billed charges,40% of total billed charges,3328.94,4980,
CT Guided Lung Biopsy ProFee,4100543,CDM,960,RC,77012,HCPCS,OUTPATIENT,,,172,103.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,82.112,other,Not separately reimbursable,,31.95,,11.168,other,Not separately reimbursable,62.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,72.048,other,Not separately reimbursable,,,,74.632,other,Not separately reimbursable,3329.94,4981,
US Guided Lung Biopsy,4100544,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,400,240,TC,340,85,,272,Percent of total billed charges,85% of total billed charges,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,82.112,fee schedule,35.15% of LA custom fee schedule,127.8,31.95,,5.112,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,92.416,case rate,pays based on per visit rate,127.8,31.95,,74.632,Fee Schedule,31.95% of LA custom fee schedule,3330.94,4982,
US Guided Lung Biopsy ProFee,4100544,CDM,960,RC,76942,HCPCS,OUTPATIENT,,,250,150,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,106.296,other,Not separately reimbursable,,31.95,,7.456,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,285.76,other,Not separately reimbursable,,,,96.616,other,Not separately reimbursable,3331.94,4983,
BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4100545,CDM,360,RC,38505,HCPCS,OUTPATIENT,,,3768,2260.8,,3202.8,85,,2562.24,Percent of total billed charges,85% of total billed charges,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1203.88,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,1203.88,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,186.352,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1507.2,40,,89.6,percent of total billed charges,40% of total billed charges,3332.94,4984,
Report,4100545,CDM,960,RC,38505,HCPCS,OUTPATIENT,,,363,217.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,203.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,71.568,other,Not separately reimbursable,,31.95,,71.568,other,Not separately reimbursable,80.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,216.144,other,Not separately reimbursable,,,,89.6,other,Not separately reimbursable,3333.94,4985,
BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4100545,CDM,360,RC,38505,HCPCS,OUTPATIENT,,,1185,711,,1007.25,85,,805.8,Percent of total billed charges,85% of total billed charges,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,378.61,31.95,,646.76,percent of total billed charges,31.95% of total billed charges,378.61,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,102.752,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,474,40,,587.88,percent of total billed charges,40% of total billed charges,3334.94,4986,
BX/EXC LYMPH NODE NEEDLE SUPERFICIAL PROF,4100545,CDM,960,RC,38505,HCPCS,OUTPATIENT,,,172,103.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,203.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,111.64,other,Not separately reimbursable,,31.95,,8.024,other,Not separately reimbursable,80.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,44.08,other,Not separately reimbursable,,,,101.472,other,Not separately reimbursable,3335.94,4987,
US Guided Biopsy Lymph Node,4100546,CDM,360,RC,38505,HCPCS,OUTPATIENT,,,3768,2260.8,TC,3202.8,85,,2562.24,Percent of total billed charges,85% of total billed charges,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1203.88,31.95,,44.712,percent of total billed charges,31.95% of total billed charges,1203.88,31.95,,10.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,44.688,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1507.2,40,,40.64,percent of total billed charges,40% of total billed charges,3336.94,4988,
Report,4100546,CDM,960,RC,38505,HCPCS,OUTPATIENT,,,363,217.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,203.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,53.68,other,Not separately reimbursable,,31.95,,53.68,other,Not separately reimbursable,80.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,44.688,other,Not separately reimbursable,,,,67.2,other,Not separately reimbursable,3337.94,4989,
US Guided Biopsy Lymph Node,4100546,CDM,402,RC,76942,HCPCS,OUTPATIENT,,,400,240,TC,340,85,,272,Percent of total billed charges,85% of total billed charges,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,194.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,168.72,fee schedule,35.15% of LA custom fee schedule,127.8,31.95,,10.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,320.72,case rate,pays based on per visit rate,127.8,31.95,,153.36,Fee Schedule,31.95% of LA custom fee schedule,3338.94,4990,
US Guided Biopsy Lymph Node ProFee,4100546,CDM,960,RC,76942,HCPCS,OUTPATIENT,,,250,150,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,1012.32,other,Not separately reimbursable,,31.95,,4.4,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,152,other,Not separately reimbursable,,,,920.16,other,Not separately reimbursable,3339.94,4991,
CT Guided Thyroid Biopsy,4100547,CDM,360,RC,60100,HCPCS,OUTPATIENT,,,1923,1153.8,TC,1634.55,85,,1307.64,Percent of total billed charges,85% of total billed charges,444.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,444.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,614.4,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,614.4,31.95,,11.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,598.88,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,769.2,40,,421.744,percent of total billed charges,40% of total billed charges,3340.94,4992,
Report,4100547,CDM,960,RC,60100,HCPCS,OUTPATIENT,,,331,198.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,148.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.88,other,Not separately reimbursable,,31.95,,5.88,other,Not separately reimbursable,72.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,347.776,other,Not separately reimbursable,,,,7.36,other,Not separately reimbursable,3341.94,4993,
CT Guided Thyroid Biopsy,4100547,CDM,360,RC,77012,HCPCS,OUTPATIENT,,,1185,711,TC,1007.25,85,,805.8,Percent of total billed charges,85% of total billed charges,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,796.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,378.61,31.95,,155.504,percent of total billed charges,31.95% of total billed charges,378.61,31.95,,13.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,45.6,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,474,40,,141.344,percent of total billed charges,40% of total billed charges,3342.94,4994,
CT Guided Thyroid Biopsy ProFee,4100547,CDM,960,RC,77012,HCPCS,OUTPATIENT,,,172,103.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,14.312,other,Not separately reimbursable,,31.95,,14.312,other,Not separately reimbursable,62.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,74.48,other,Not separately reimbursable,,,,17.92,other,Not separately reimbursable,3343.94,4995,
US Guided Thyroid Biopsy,4100548,CDM,360,RC,60100,HCPCS,OUTPATIENT,,,1923,1153.8,TC,1634.55,85,,1307.64,Percent of total billed charges,85% of total billed charges,444.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,444.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,614.4,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,614.4,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,425.6,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,769.2,40,,17.92,percent of total billed charges,40% of total billed charges,3344.94,4996,
Report,4100548,CDM,960,RC,60100,HCPCS,OUTPATIENT,,,331,198.6,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,148.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,23.256,other,Not separately reimbursable,,31.95,,23.256,other,Not separately reimbursable,72.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,60.8,other,Not separately reimbursable,,,,29.12,other,Not separately reimbursable,3345.94,4997,
US Drainage Catheter,4100549,CDM,320,RC,10030,HCPCS,OUTPATIENT,,,3768,2260.8,TC,3202.8,85,,2562.24,Percent of total billed charges,85% of total billed charges,671.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,671.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1203.88,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,1203.88,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,155,100,,152,case rate,pays based on per visit rate,1507.2,40,,29.12,percent of total billed charges,40% of total billed charges,3346.94,4998,
Report,4100549,CDM,972,RC,10030,HCPCS,OUTPATIENT,,,525,315,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,598.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.912,other,Not separately reimbursable,,31.95,,18.912,other,Not separately reimbursable,127.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,152,other,Not separately reimbursable,,,,23.68,other,Not separately reimbursable,3347.94,4999,
Report,4100600,CDM,972,RC,93970,HCPCS,OUTPATIENT,,,105,63,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,243.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.912,other,Not separately reimbursable,,31.95,,18.912,other,Not separately reimbursable,105,100,,,fee schedule,100% of CMS physician fee schedule,,,,152,other,Not separately reimbursable,,,,23.68,other,Not separately reimbursable,3348.94,5000,
US LE Venous Duplex Bilateral,4100600,CDM,921,RC,93970,HCPCS,OUTPATIENT,,,612,367.2,26,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,514.82,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,215.12,35.15,,18.912,fee schedule,35.15% of LA custom fee schedule,195.53,31.95,,18.912,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,152,case rate,pays based on per visit rate,195.53,31.95,,23.68,Fee Schedule,31.95% of LA custom fee schedule,3349.94,5001,
Report,4100601,CDM,972,RC,93971,HCPCS,OUTPATIENT,,,68,40.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,18.912,other,Not separately reimbursable,,31.95,,18.912,other,Not separately reimbursable,68,100,,,fee schedule,100% of CMS physician fee schedule,,,,152,other,Not separately reimbursable,,,,23.68,other,Not separately reimbursable,3350.94,5002,
US LE Venous Duplex Left,4100601,CDM,921,RC,93971,HCPCS,OUTPATIENT,,,425,255,26,361.25,85,,289,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,242.824,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,242.824,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,152,case rate,pays based on per visit rate,135.79,31.95,,304,Fee Schedule,31.95% of LA custom fee schedule,3351.94,5003,
Report,4100602,CDM,972,RC,93971,HCPCS,OUTPATIENT,,,68,40.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,5.112,other,Not separately reimbursable,,31.95,,5.112,other,Not separately reimbursable,68,100,,,fee schedule,100% of CMS physician fee schedule,,,,152,other,Not separately reimbursable,,,,6.4,other,Not separately reimbursable,3352.94,5004,
US LE Venous Duplex Right,4100602,CDM,921,RC,93971,HCPCS,OUTPATIENT,,,425,255,26,361.25,85,,289,Percent of total billed charges,85% of total billed charges,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,320.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,149.39,35.15,,14.824,fee schedule,35.15% of LA custom fee schedule,135.79,31.95,,14.824,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,250,100,,152,case rate,pays based on per visit rate,135.79,31.95,,18.56,Fee Schedule,31.95% of LA custom fee schedule,3353.94,5005,
XR Femur 1 View Left,4100603,CDM,320,RC,73551,HCPCS,OUTPATIENT,,,230,138,LT,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,47.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,47.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,86.608,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,13.008,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,152,case rate,pays based on per visit rate,73.49,31.95,,78.728,Fee Schedule,31.95% of LA custom fee schedule,3354.94,5006,
Report,4100603,CDM,972,RC,73551,HCPCS,OUTPATIENT,,,28,16.8,LT,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,121.92,other,Not separately reimbursable,,31.95,,121.92,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,152,other,Not separately reimbursable,,,,152.64,other,Not separately reimbursable,3355.94,5007,
XR Femur 1 View Right,4100604,CDM,320,RC,73551,HCPCS,OUTPATIENT,,,230,138,1-RT|2-TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,47.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,47.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,897.032,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,15.056,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,152,case rate,pays based on per visit rate,73.49,31.95,,815.368,Fee Schedule,31.95% of LA custom fee schedule,3356.94,5008,
Report,4100604,CDM,972,RC,73551,HCPCS,OUTPATIENT,,,28,16.8,1-RT|2-TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,104.888,other,Not separately reimbursable,,31.95,,21.24,other,Not separately reimbursable,18.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,38,other,Not separately reimbursable,,,,95.336,other,Not separately reimbursable,3357.94,5009,
US BIOPSY OF SALIVARY GLAND,4100605,CDM,360,RC,42400,HCPCS,OUTPATIENT,,,2156,1293.6,TC,1832.6,85,,1466.08,Percent of total billed charges,85% of total billed charges,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,897.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,688.84,31.95,,80.144,percent of total billed charges,31.95% of total billed charges,688.84,31.95,,27.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,47.12,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,862.4,40,,72.848,percent of total billed charges,40% of total billed charges,3358.94,5010,
Report,4100605,CDM,972,RC,42400,HCPCS,OUTPATIENT,,,228,136.8,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,152.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,104.888,other,Not separately reimbursable,,31.95,,32.552,other,Not separately reimbursable,49.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,42.56,other,Not separately reimbursable,,,,95.336,other,Not separately reimbursable,3359.94,5011,
US Thoracentesis Guided,4100606,CDM,320,RC,32555,HCPCS,OUTPATIENT,,,1941,1164.6,TC,1649.85,85,,1319.88,Percent of total billed charges,85% of total billed charges,1734.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1734.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,620.15,31.95,,135.536,percent of total billed charges,31.95% of total billed charges,620.15,31.95,,24.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,155,100,,18.24,case rate,pays based on per visit rate,776.4,40,,123.2,percent of total billed charges,40% of total billed charges,3360.94,5012,
US Thoracentesis Guided Profee,4100606,CDM,972,RC,32555,HCPCS,OUTPATIENT,,,455,273,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,436.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,126.544,other,Not separately reimbursable,,31.95,,24.92,other,Not separately reimbursable,103.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,15.2,other,Not separately reimbursable,,,,115.024,other,Not separately reimbursable,3361.94,5013,
US Aspiration Thyroid Cyst,4100615,CDM,360,RC,60300,HCPCS,OUTPATIENT,,,1850,1110,,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,1159.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1159.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,591.08,31.95,,39.368,percent of total billed charges,31.95% of total billed charges,591.08,31.95,,79.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,13.68,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,740,40,,35.784,percent of total billed charges,40% of total billed charges,3362.94,5014,
PROFEE,4100615,CDM,972,RC,60300,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,148.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,133.848,other,Not separately reimbursable,,31.95,,444.088,other,Not separately reimbursable,45.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,10.64,other,Not separately reimbursable,,,,121.664,other,Not separately reimbursable,3363.94,5015,
PROF FLUOROGUIDANCE NEEDLE PLACEMENT,4100650,CDM,972,RC,77002,HCPCS,OUTPATIENT,,,320,192,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,126.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,207.808,other,Not separately reimbursable,,31.95,,29.904,other,Not separately reimbursable,78.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,14.592,other,Not separately reimbursable,,,,188.888,other,Not separately reimbursable,3364.94,5016,
FLUORO GUIDANCE NEEDLE PLACEMENT,4100650,CDM,320,RC,77002,HCPCS,OUTPATIENT,,,50,30,26,42.5,85,,34,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.58,35.15,,133.848,fee schedule,35.15% of LA custom fee schedule,15.98,31.95,,59.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,155,100,,7.6,case rate,pays based on per visit rate,15.98,31.95,,121.664,Fee Schedule,31.95% of LA custom fee schedule,3365.94,5017,
MAMMO DIAGNOSTIC DBT UNILAT,4100661,CDM,401,RC,77061,HCPCS,OUTPATIENT,,,145,87,TC,123.25,85,,98.6,Percent of total billed charges,85% of total billed charges,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,50.97,35.15,,32.616,fee schedule,35.15% of LA custom fee schedule,46.33,31.95,,59.808,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,369.36,case rate,pays based on per visit rate,46.33,31.95,,29.648,Fee Schedule,31.95% of LA custom fee schedule,3366.94,5018,
Report,4100661,CDM,972,RC,77061,HCPCS,OUTPATIENT,,,50,30,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,166.752,other,Not separately reimbursable,,31.95,,78.752,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,369.36,other,Not separately reimbursable,,,,151.568,other,Not separately reimbursable,3367.94,5019,
FMC Mammo Daig 3D Bilat Add on,4100662,CDM,401,RC,77062,HCPCS,OUTPATIENT,,,178,106.8,,151.3,85,,121.04,Percent of total billed charges,85% of total billed charges,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.57,35.15,,82.672,fee schedule,35.15% of LA custom fee schedule,56.87,31.95,,104.672,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,342,case rate,pays based on per visit rate,56.87,31.95,,75.144,Fee Schedule,31.95% of LA custom fee schedule,3368.94,5020,
FMC Mammo Diag 3D Bilat Add on PF,4100662,CDM,972,RC,77062,HCPCS,OUTPATIENT,,,55,33,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,140.6,other,Not separately reimbursable,,31.95,,1619.408,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,463.6,other,Not separately reimbursable,,,,127.8,other,Not separately reimbursable,3369.94,5021,
FMC 77063 Add on,4100663,CDM,403,RC,77063,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,43.94,35.15,,127.944,fee schedule,35.15% of LA custom fee schedule,39.94,31.95,,1780.472,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,50.16,case rate,pays based on per visit rate,39.94,31.95,,116.296,Fee Schedule,31.95% of LA custom fee schedule,3370.94,5022,
FMC 77063 Add on PF,4100663,CDM,972,RC,77063,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,32.616,other,Not separately reimbursable,,31.95,,2.56,other,Not separately reimbursable,21.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,136.192,other,Not separately reimbursable,,,,29.648,other,Not separately reimbursable,3371.94,5023,
MAMMO SCREENING DBT LT/RT,4100664,CDM,403,RC,77063,HCPCS,OUTPATIENT,,,125,75,1-TC|2-52,106.25,85,,85,Percent of total billed charges,85% of total billed charges,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,43.94,35.15,,927.832,fee schedule,35.15% of LA custom fee schedule,39.94,31.95,,927.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,300,100,,175.712,case rate,pays based on per visit rate,39.94,31.95,,1161.6,Fee Schedule,31.95% of LA custom fee schedule,3372.94,5024,
Report 77063,4100664,CDM,972,RC,77063,HCPCS,OUTPATIENT,,,65,39,1-TC|2-52,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,37.576,other,Not separately reimbursable,,31.95,,37.576,other,Not separately reimbursable,21.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,175.712,other,Not separately reimbursable,,,,47.04,other,Not separately reimbursable,3373.94,5025,
CT Low Dose Lung Screening,4100700,CDM,352,RC,71271,HCPCS,OUTPATIENT,,,500,300,TC,425,85,,340,Percent of total billed charges,85% of total billed charges,187.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,187.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,52.304,fee schedule,35.15% of LA custom fee schedule,159.75,31.95,,9.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,9.424,case rate,pays based on per visit rate,159.75,31.95,,47.544,Fee Schedule,31.95% of LA custom fee schedule,3374.94,5026,
CT Low Dose Lung Screening,4100700,CDM,972,RC,71271,HCPCS,OUTPATIENT,,,155,93,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,195.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,52.304,other,Not separately reimbursable,,31.95,,9.608,other,Not separately reimbursable,79.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,9.424,other,Not separately reimbursable,,,,47.544,other,Not separately reimbursable,3375.94,5027,
CT Heart w/o Contrast w/Calcium Test,4100710,CDM,350,RC,75571,HCPCS,OUTPATIENT,,,230,138,TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,104.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,104.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,52.304,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,9.84,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,13.68,case rate,pays based on per visit rate,73.49,31.95,,47.544,Fee Schedule,31.95% of LA custom fee schedule,3376.94,5028,
CT Heart and Coronary Arteries,4100710,CDM,972,RC,75571,HCPCS,OUTPATIENT,,,87,52.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,8.432,other,Not separately reimbursable,,31.95,,8.432,other,Not separately reimbursable,66.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,61.712,other,Not separately reimbursable,,,,10.56,other,Not separately reimbursable,3377.94,5029,
CT Cardiac Calcium Score,4100710,CDM,350,RC,75571,HCPCS,OUTPATIENT,,,230,138,TC,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,104.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,104.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,15.08,fee schedule,35.15% of LA custom fee schedule,73.49,31.95,,15.08,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,653.6,case rate,pays based on per visit rate,73.49,31.95,,18.88,Fee Schedule,31.95% of LA custom fee schedule,3378.94,5030,
Report,4100710,CDM,972,RC,75571,HCPCS,OUTPATIENT,,,87,52.2,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,30.16,other,Not separately reimbursable,,31.95,,30.16,other,Not separately reimbursable,66.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,729.6,other,Not separately reimbursable,,,,37.76,other,Not separately reimbursable,3379.94,5031,
FMC 3D RENDERING W/INTERP  POSTPROCESS SUPERVISION,4100720,CDM,350,RC,76376,HCPCS,OUTPATIENT,,,69,41.4,TC,58.65,85,,46.92,Percent of total billed charges,85% of total billed charges,84.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.25,35.15,,1138.864,fee schedule,35.15% of LA custom fee schedule,22.05,31.95,,11.336,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,653.6,case rate,pays based on per visit rate,22.05,31.95,,1035.184,Fee Schedule,31.95% of LA custom fee schedule,3380.94,5032,
FMC 3D RENDERING W/INTERP  POSTPROCESS SUPERVISION,4100720,CDM,972,RC,76376,HCPCS,OUTPATIENT,,,30,18,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,29.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,548.344,other,Not separately reimbursable,,31.95,,8.424,other,Not separately reimbursable,13.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,25.84,other,Not separately reimbursable,,,,498.424,other,Not separately reimbursable,3381.94,5033,
FMC 3D RENDERING DIFF WORK STATION,4100721,CDM,350,RC,76377,HCPCS,OUTPATIENT,,,200,120,TC,170,85,,136,Percent of total billed charges,85% of total billed charges,219.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,219.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,548.344,fee schedule,35.15% of LA custom fee schedule,63.9,31.95,,9.376,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,525,100,,14.288,case rate,pays based on per visit rate,63.9,31.95,,498.424,Fee Schedule,31.95% of LA custom fee schedule,3382.94,5034,
FMC 3D RENDERING DIFF WORK STATION,4100721,CDM,972,RC,76377,HCPCS,OUTPATIENT,,,120,72,TC,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,467.352,other,Not separately reimbursable,,31.95,,9.376,other,Not separately reimbursable,35.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,18.848,other,Not separately reimbursable,,,,424.808,other,Not separately reimbursable,3383.94,5035,
albuterol 0.042% Inh Sol 1.25mg/3 mL [FMC],4126595,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,17.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,390.64,percent of total billed charges,38% of total billed charges,3.83,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,3384.94,5036,
albuterol 0.042% Inh Sol 1.25mg/3 mL [FMC],4126595,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,19.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,25.84,percent of total billed charges,38% of total billed charges,3.83,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,3385.94,5037,
albuterol 0.042% Inh Sol 1.25mg/3 mL [FMC],4126595,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,32.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,12.768,percent of total billed charges,38% of total billed charges,3.83,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,3386.94,5038,
CPAP VENTILATION CPAP INITIATIONMGMT,4140230,CDM,410,RC,94660,HCPCS,OUTPATIENT,,,1048,628.8,,890.8,85,,712.64,Percent of total billed charges,85% of total billed charges,250.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,368.37,35.15,,253.08,fee schedule,35.15% of LA custom fee schedule,334.84,31.95,,5.48,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,92.72,case rate,pays based on per visit rate,334.84,31.95,,230.04,Fee Schedule,31.95% of LA custom fee schedule,3387.94,5039,
HC HTD HIGH FLOW NSL CANN INITIAL Hi-VNI,4140237,CDM,460,RC,94799,HCPCS,OUTPATIENT,,,420,252,,357,85,,285.6,Percent of total billed charges,85% of total billed charges,131.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,131.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,147.63,35.15,,11.504,fee schedule,35.15% of LA custom fee schedule,134.19,31.95,,11.504,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,190,case rate,pays based on per visit rate,134.19,31.95,,14.4,Fee Schedule,31.95% of LA custom fee schedule,3388.94,5040,
HC HTD HIGH FLOW NSL CANN SUBQ Hi-VNI,4140238,CDM,460,RC,94799,HCPCS,OUTPATIENT,,,280,168,,238,85,,190.4,Percent of total billed charges,85% of total billed charges,131.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,131.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,98.42,35.15,,140.6,fee schedule,35.15% of LA custom fee schedule,89.46,31.95,,6.208,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,110,100,,38,case rate,pays based on per visit rate,89.46,31.95,,127.8,Fee Schedule,31.95% of LA custom fee schedule,3389.94,5041,
SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME,4140239,CDM,920,RC,95800,HCPCS,OUTPATIENT,,,375,225,,318.75,85,,255,Percent of total billed charges,85% of total billed charges,433.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,433.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,131.81,35.15,,127.8,fee schedule,35.15% of LA custom fee schedule,119.81,31.95,,127.8,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,100.32,case rate,pays based on per visit rate,119.81,31.95,,160,Fee Schedule,31.95% of LA custom fee schedule,3390.94,5042,
Polysomnography,4140240,CDM,920,RC,95810,HCPCS,OUTPATIENT,,,4500,2700,,3825,85,,3060,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1581.75,35.15,,178.92,fee schedule,35.15% of LA custom fee schedule,1437.75,31.95,,178.92,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,28.88,case rate,pays based on per visit rate,1437.75,31.95,,224,Fee Schedule,31.95% of LA custom fee schedule,3391.94,5043,
Polysomnography,4140240,CDM,920,RC,95810,HCPCS,OUTPATIENT,,,4500,2700,,3825,85,,3060,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1581.75,35.15,,69.016,fee schedule,35.15% of LA custom fee schedule,1437.75,31.95,,69.016,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,97.28,case rate,pays based on per visit rate,1437.75,31.95,,86.4,Fee Schedule,31.95% of LA custom fee schedule,3392.94,5044,
Polysomnography w/CPAP,4140257,CDM,920,RC,95811,HCPCS,OUTPATIENT,,,4950,2970,,4207.5,85,,3366,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1739.93,35.15,,146.224,fee schedule,35.15% of LA custom fee schedule,1581.53,31.95,,114.608,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,114.912,case rate,pays based on per visit rate,1581.53,31.95,,132.912,Fee Schedule,31.95% of LA custom fee schedule,3393.94,5045,
Polysomnography w/CPAP,4140257,CDM,920,RC,95811,HCPCS,OUTPATIENT,,,4950,2970,,4207.5,85,,3366,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1739.93,35.15,,140.6,fee schedule,35.15% of LA custom fee schedule,1581.53,31.95,,4408.024,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,41.04,case rate,pays based on per visit rate,1581.53,31.95,,127.8,Fee Schedule,31.95% of LA custom fee schedule,3394.94,5046,
PSG < 6 YEARS OLD,4140260,CDM,920,RC,95782,HCPCS,OUTPATIENT,,,4000,2400,,3400,85,,2720,Percent of total billed charges,85% of total billed charges,2813.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2813.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1406,35.15,,1138.864,fee schedule,35.15% of LA custom fee schedule,1278,31.95,,9.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,16.112,case rate,pays based on per visit rate,1278,31.95,,1035.184,Fee Schedule,31.95% of LA custom fee schedule,3395.94,5047,
PSG < 6 YEARS OLD,4140260,CDM,920,RC,95782,HCPCS,OUTPATIENT,,,4000,2400,,3400,85,,2720,Percent of total billed charges,85% of total billed charges,2813.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,2813.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1406,35.15,,717.064,fee schedule,35.15% of LA custom fee schedule,1278,31.95,,9.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175,100,,165.68,case rate,pays based on per visit rate,1278,31.95,,651.784,Fee Schedule,31.95% of LA custom fee schedule,3396.94,5048,
Multiple Sleep Latency Test,4140265,CDM,410,RC,95805,HCPCS,OUTPATIENT,,,3500,2100,,2975,85,,2380,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1230.25,35.15,,548.344,fee schedule,35.15% of LA custom fee schedule,1118.25,31.95,,9.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,159.6,case rate,pays based on per visit rate,1118.25,31.95,,498.424,Fee Schedule,31.95% of LA custom fee schedule,3397.94,5049,
Multiple Sleep Latency Test,4140265,CDM,410,RC,95805,HCPCS,OUTPATIENT,,,3500,2100,,2975,85,,2380,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1230.25,35.15,,253.08,fee schedule,35.15% of LA custom fee schedule,1118.25,31.95,,9.2,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,131.936,case rate,pays based on per visit rate,1118.25,31.95,,230.04,Fee Schedule,31.95% of LA custom fee schedule,3398.94,5050,
Day Time Sleep Study,4140273,CDM,410,RC,95807,HCPCS,OUTPATIENT,,,3500,2100,,2975,85,,2380,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1230.25,35.15,,1012.32,fee schedule,35.15% of LA custom fee schedule,1118.25,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,131.936,case rate,pays based on per visit rate,1118.25,31.95,,920.16,Fee Schedule,31.95% of LA custom fee schedule,3399.94,5051,
Day Time Sleep Study,4140273,CDM,410,RC,95807,HCPCS,OUTPATIENT,,,3500,2100,,2975,85,,2380,Percent of total billed charges,85% of total billed charges,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1796.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1230.25,35.15,,506.16,fee schedule,35.15% of LA custom fee schedule,1118.25,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,27.36,case rate,pays based on per visit rate,1118.25,31.95,,460.08,Fee Schedule,31.95% of LA custom fee schedule,3400.94,5052,
HST W/TYPE III PRTBLE MON UNATTENDED MIN 4 CH,4140278,CDM,920,RC,G0399,HCPCS,OUTPATIENT,,,510,306,,433.5,85,,346.8,Percent of total billed charges,85% of total billed charges,461.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,461.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,179.27,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,27.36,case rate,pays based on per visit rate,162.95,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,3401.94,5053,
"RCM; image acquisition only, first lesion",4142002,CDM,940,RC,96932,HCPCS,OUTPATIENT,,,280,168,,238,85,,190.4,Percent of total billed charges,85% of total billed charges,103.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,103.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,89.46,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,89.46,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,279.68,case rate,pays based on per visit rate,112,40,,421.744,percent of total billed charges,40% of total billed charges,3402.94,5054,
"RCM; Image acquisition only, each additional lesion",4142005,CDM,940,RC,96935,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,31.95,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,205.2,case rate,pays based on per visit rate,40,40,,80,percent of total billed charges,40% of total billed charges,3403.94,5055,
RT Sputum Collection Charge,4143061,CDM,410,RC,89220,HCPCS,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,49.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.18,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,140,100,,319.2,case rate,pays based on per visit rate,38.34,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,3404.94,5056,
Intubation Assist,4143152,CDM,410,RC,31500,HCPCS,OUTPATIENT,,,639,383.4,,543.15,85,,434.52,Percent of total billed charges,85% of total billed charges,615.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,615.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,224.61,35.15,,1012.32,fee schedule,35.15% of LA custom fee schedule,204.16,31.95,,3.576,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,65.36,case rate,pays based on per visit rate,204.16,31.95,,920.16,Fee Schedule,31.95% of LA custom fee schedule,3405.94,5057,
RT Cardiopulmonary Resuscitation Charge,4143426,CDM,410,RC,92950,HCPCS,OUTPATIENT,,,490,294,,416.5,85,,333.2,Percent of total billed charges,85% of total billed charges,615.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,615.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,172.24,35.15,,463.984,fee schedule,35.15% of LA custom fee schedule,156.56,31.95,,3.592,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,10.336,case rate,pays based on per visit rate,156.56,31.95,,421.744,Fee Schedule,31.95% of LA custom fee schedule,3406.94,5058,
CPR 1/2 Hour,4143426,CDM,410,RC,92950,HCPCS,OUTPATIENT,,,490,294,,416.5,85,,333.2,Percent of total billed charges,85% of total billed charges,615.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,615.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,172.24,35.15,,166.144,fee schedule,35.15% of LA custom fee schedule,156.56,31.95,,166.144,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,3.952,case rate,pays based on per visit rate,156.56,31.95,,208,Fee Schedule,31.95% of LA custom fee schedule,3407.94,5059,
CYSTO TUBE CHANGE SIMPLE,4143505,CDM,361,RC,51705,HCPCS,OUTPATIENT,,,625,375,,531.25,85,,425,Percent of total billed charges,85% of total billed charges,560.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,560.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,199.69,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,199.69,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,15.2,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,250,40,,11.2,percent of total billed charges,40% of total billed charges,3408.94,5060,
BLADDER INSTILLATION OF ANTICARCINOGEN,4143510,CDM,490,RC,51720,HCPCS,OUTPATIENT,,,1400,840,,1190,85,,952,Percent of total billed charges,85% of total billed charges,653.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,653.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,395.29,110,,10.224,fee schedule,110% of Asc Tier Grouping Fee Schedule,359.35,100,,10.224,fee schedule,100% of Asc Tier Grouping Fee Schedule,,,,,other,Not separately reimbursable,385,100,,19.76,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,359.35,100,,12.8,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,3409.94,5061,
RT Arterial Puncture Charge,4143566,CDM,360,RC,36600,HCPCS,OUTPATIENT,,,295,177,59,250.75,85,,200.6,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,94.25,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,94.25,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,10.12,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,118,40,,32,percent of total billed charges,40% of total billed charges,3410.94,5062,
CYSTOURETHROSCOPY,4143600,CDM,361,RC,52000,HCPCS,OUTPATIENT,,,1685,1011,,1432.25,85,,1145.8,Percent of total billed charges,85% of total billed charges,1737.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,538.36,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,538.36,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,28.576,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,674,40,,498.424,percent of total billed charges,40% of total billed charges,3411.94,5063,
94016 PFT INTERPRETATION CHARGE,4143624,CDM,976,RC,94016,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,253.08,other,Not separately reimbursable,,31.95,,4.136,other,Not separately reimbursable,23.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,104.88,other,Not separately reimbursable,,,,230.04,other,Not separately reimbursable,3412.94,5064,
CYSTO W/REM OF FB/STENT SIMPLE,4143660,CDM,361,RC,52310,HCPCS,OUTPATIENT,,,1905,1143,,1619.25,85,,1295.4,Percent of total billed charges,85% of total billed charges,1737.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1737.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,608.65,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,608.65,31.95,,5.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1300,100,,90.592,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,762,40,,690.12,percent of total billed charges,40% of total billed charges,3413.94,5065,
DILATION URETH STRICT MALE INITIAL,4143800,CDM,361,RC,53600,HCPCS,OUTPATIENT,,,600,360,,510,85,,408,Percent of total billed charges,85% of total billed charges,653.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,653.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,191.7,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,191.7,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,12.816,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,240,40,,460.08,percent of total billed charges,40% of total billed charges,3414.94,5066,
DILATION URETH STRICT MALE SBSQ,4143801,CDM,361,RC,53601,HCPCS,OUTPATIENT,,,315,189,,267.75,85,,214.2,Percent of total billed charges,85% of total billed charges,290.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,290.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,110.72,35.15,,210.904,fee schedule,35.15% of LA custom fee schedule,100.64,31.95,,38.344,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,145.008,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,100.64,31.95,,191.704,Fee Schedule,31.95% of LA custom fee schedule,3415.94,5067,
DILATION URETHRA FEMALE INITIAL,4143820,CDM,361,RC,53660,HCPCS,OUTPATIENT,,,385,231,,327.25,85,,261.8,Percent of total billed charges,85% of total billed charges,290.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,290.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.33,35.15,,47.24,fee schedule,35.15% of LA custom fee schedule,123.01,31.95,,4.848,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,130.416,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,123.01,31.95,,42.944,Fee Schedule,31.95% of LA custom fee schedule,3416.94,5068,
DILATION URETHRA FEMALE SBSQ,4143821,CDM,361,RC,53661,HCPCS,OUTPATIENT,,,315,189,,267.75,85,,214.2,Percent of total billed charges,85% of total billed charges,290.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,290.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,110.72,35.15,,44.712,fee schedule,35.15% of LA custom fee schedule,100.64,31.95,,5.616,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,145.008,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,100.64,31.95,,40.64,Fee Schedule,31.95% of LA custom fee schedule,3417.94,5069,
S9441 ASTHMA EDUCATION CHARGE,4143970,CDM,942,RC,S9441,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.5,50,,22,percent of total billed charges,50% of total billed charges,17.57,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,90,100,,145.008,case rate,pays based on per visit rate,22,40,,36.8,percent of total billed charges,40% of total billed charges,3418.94,5070,
IPPB Initial,4144002,CDM,410,RC,94640,HCPCS,OUTPATIENT,,,235,141,76,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,69.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,82.6,35.15,,717.064,fee schedule,35.15% of LA custom fee schedule,75.08,31.95,,5.968,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,130.416,case rate,pays based on per visit rate,75.08,31.95,,651.784,Fee Schedule,31.95% of LA custom fee schedule,3419.94,5071,
"Aero, Large Volume Heated, Daily Charge",4144010,CDM,410,RC,94640,HCPCS,OUTPATIENT,,,235,141,,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,69.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,82.6,35.15,,253.08,fee schedule,35.15% of LA custom fee schedule,75.08,31.95,,6.456,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,12.816,case rate,pays based on per visit rate,75.08,31.95,,230.04,Fee Schedule,31.95% of LA custom fee schedule,3420.94,5072,
EVALUATE PT USE OF INHALER,4144014,CDM,410,RC,94664,HCPCS,OUTPATIENT,,,560,336,,476,85,,380.8,Percent of total billed charges,85% of total billed charges,69.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,69.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,196.84,35.15,,3.832,fee schedule,35.15% of LA custom fee schedule,178.92,31.95,,3.832,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,12.816,case rate,pays based on per visit rate,178.92,31.95,,4.8,Fee Schedule,31.95% of LA custom fee schedule,3421.94,5073,
budesonide 0.5 mg/2 mL Inh Susp [FMC],4144077,CDM,250,RC,,,OUTPATIENT,1,ML,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,12.816,percent of total billed charges,38% of total billed charges,7.2,40,,6.4,percent of total billed charges,40% of total billed charges,3422.94,5074,
budesonide 0.5 mg/2 mL Inh Susp [FMC],4144077,CDM,250,RC,,,OUTPATIENT,1,ML,18.14,10.884,,15.42,85,,12.336,Percent of total billed charges,85% of total billed charges,9.07,50,,7.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.07,50,,7.256,percent of total billed charges,50% of total billed charges,5.8,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,5.8,31.95,,13.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.89,38,,12.816,percent of total billed charges,38% of total billed charges,7.26,40,,920.16,percent of total billed charges,40% of total billed charges,3423.94,5075,
budesonide 0.5 mg/2 mL Inh Susp [FMC],4144077,CDM,250,RC,,,OUTPATIENT,1,ML,18.14,10.884,,15.42,85,,12.336,Percent of total billed charges,85% of total billed charges,9.07,50,,7.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.07,50,,7.256,percent of total billed charges,50% of total billed charges,5.8,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,5.8,31.95,,14.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.89,38,,12.816,percent of total billed charges,38% of total billed charges,7.26,40,,1035.184,percent of total billed charges,40% of total billed charges,3424.94,5076,
6 minute walk test,4144119,CDM,410,RC,94618,HCPCS,OUTPATIENT,,,267,160.2,,226.95,85,,181.56,Percent of total billed charges,85% of total billed charges,192.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,192.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,93.85,35.15,,1138.864,fee schedule,35.15% of LA custom fee schedule,85.31,31.95,,3239.728,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,12.816,case rate,pays based on per visit rate,85.31,31.95,,1035.184,Fee Schedule,31.95% of LA custom fee schedule,3425.94,5077,
ipratropium 0.02% Inh Sol 0.5mg/2.5 mL [FMC],4160107,CDM,250,RC,,,OUTPATIENT,2.5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,590.52,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,425.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,12.816,percent of total billed charges,38% of total billed charges,4.8,40,,536.76,percent of total billed charges,40% of total billed charges,3426.94,5078,
ipratropium 0.02% Inh Sol 0.5mg/2.5 mL [FMC],4160107,CDM,250,RC,,,OUTPATIENT,2.5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,12.816,percent of total billed charges,38% of total billed charges,4.8,40,,498.424,percent of total billed charges,40% of total billed charges,3427.94,5079,
ipratropium 0.02% Inh Sol 0.5mg/2.5 mL [FMC],4160107,CDM,250,RC,,,OUTPATIENT,2.5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,585.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,7.48,percent of total billed charges,38% of total billed charges,4.8,40,,230.04,percent of total billed charges,40% of total billed charges,3428.94,5080,
ipratropium 0.02% Inh Sol 0.5mg/2.5 mL [FMC],4160107,CDM,250,RC,,,OUTPATIENT,2.5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,74.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,52.896,percent of total billed charges,38% of total billed charges,4.8,40,,920.16,percent of total billed charges,40% of total billed charges,3429.94,5081,
ipratropium 0.02% Inh Sol 0.5mg/2.5 mL [FMC],4160107,CDM,250,RC,,,OUTPATIENT,2.5,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,7.48,percent of total billed charges,38% of total billed charges,4.8,40,,920.16,percent of total billed charges,40% of total billed charges,3430.94,5082,
sodium chloride 0.9% Inh Sol 3 mL [FMC],4163952,CDM,250,RC,,,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,99.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,69.92,percent of total billed charges,38% of total billed charges,4.8,40,,421.744,percent of total billed charges,40% of total billed charges,3431.94,5083,
sodium chloride 0.9% Inh Sol 3 mL [FMC],4163952,CDM,250,RC,,,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,84.816,percent of total billed charges,38% of total billed charges,4.8,40,,6.4,percent of total billed charges,40% of total billed charges,3432.94,5084,
sodium chloride 0.9% Inh Sol 3 mL [FMC],4163952,CDM,250,RC,,,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,7.48,percent of total billed charges,38% of total billed charges,4.8,40,,5.44,percent of total billed charges,40% of total billed charges,3433.94,5085,
levalbuterol 1.25 mg/0.5 mL Inh Sol [FMC],4169066,CDM,250,RC,J7612,HCPCS,OUTPATIENT,1,ML,21.78,13.068,,18.51,85,,14.808,Percent of total billed charges,85% of total billed charges,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.66,35.15,,3.192,percent of total billed charges,35.15% of total billed charges,111.19,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.28,38,,7.48,percent of total billed charges,38% of total billed charges,6.96,31.95,,4,percent of total billed charges,31.95% of total billed charges,3434.94,5086,
levalbuterol 1.25 mg/3 mL Inh Sol [FMC],4169066,CDM,250,RC,J7614,HCPCS,OUTPATIENT,1,ML,31.92,19.152,,27.13,85,,21.704,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,11.22,35.15,,3.832,percent of total billed charges,35.15% of total billed charges,111.83,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.13,38,,7.48,percent of total billed charges,38% of total billed charges,10.2,31.95,,4.8,percent of total billed charges,31.95% of total billed charges,3435.94,5087,
levalbuterol 1.25 mg/3 mL Inh Sol [FMC],4169066,CDM,250,RC,J7614,HCPCS,OUTPATIENT,1,ML,21.77,13.062,,18.5,85,,14.8,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.65,35.15,,153.36,percent of total billed charges,35.15% of total billed charges,111.83,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.27,38,,7.48,percent of total billed charges,38% of total billed charges,6.96,31.95,,192,percent of total billed charges,31.95% of total billed charges,3436.94,5088,
levalbuterol 1.25 mg/0.5 mL Inh Sol [FMC],4169066,CDM,250,RC,J7612,HCPCS,OUTPATIENT,1,ML,21.78,13.068,,18.51,85,,14.808,Percent of total billed charges,85% of total billed charges,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.66,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,111.83,31.95,,116.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.28,38,,70.528,percent of total billed charges,38% of total billed charges,6.96,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,3437.94,5089,
levalbuterol 1.25 mg/0.5 mL Inh Sol [FMC],4169066,CDM,250,RC,J7612,HCPCS,OUTPATIENT,1,ML,27.75,16.65,,23.59,85,,18.872,Percent of total billed charges,85% of total billed charges,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,9.75,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,111.83,31.95,,116.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.55,38,,7.48,percent of total billed charges,38% of total billed charges,8.87,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,3438.94,5090,
levalbuterol 1.25 mg/3 mL Inh Sol [FMC],4169066,CDM,250,RC,J7614,HCPCS,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,111.83,31.95,,128.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,7.48,percent of total billed charges,38% of total billed charges,3.83,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,3439.94,5091,
levalbuterol 1.25 mg/3 mL Inh Sol [FMC],4169066,CDM,250,RC,J7614,HCPCS,OUTPATIENT,1,ML,21.79,13.074,,18.52,85,,14.816,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.66,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,113.42,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.28,38,,7.48,percent of total billed charges,38% of total billed charges,6.96,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,3440.94,5092,
levalbuterol 1.25 mg/0.5 mL Inh Sol [FMC],4169066,CDM,250,RC,J7612,HCPCS,OUTPATIENT,1,ML,21.77,13.062,,18.5,85,,14.8,Percent of total billed charges,85% of total billed charges,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.34,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.65,35.15,,3.192,percent of total billed charges,35.15% of total billed charges,113.42,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.27,38,,7.48,percent of total billed charges,38% of total billed charges,6.96,31.95,,4,percent of total billed charges,31.95% of total billed charges,3441.94,5093,
levalbuterol 1.25 mg/3 mL Inh Sol [FMC],4169066,CDM,250,RC,J7614,HCPCS,OUTPATIENT,1,ML,38.58,23.148,,32.79,85,,26.232,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.56,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,113.42,31.95,,1293.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.66,38,,7.48,percent of total billed charges,38% of total billed charges,12.33,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,3442.94,5094,
levalbuterol 1.25 mg/3 mL Inh Sol [FMC],4169066,CDM,250,RC,J7614,HCPCS,OUTPATIENT,1,ML,20.93,12.558,,17.79,85,,14.232,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.36,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,113.74,31.95,,278.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.95,38,,7.48,percent of total billed charges,38% of total billed charges,6.69,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,3443.94,5095,
levalbuterol 0.63 mg/3 mL Inh Sol [FMC],4169090,CDM,250,RC,J7614,HCPCS,OUTPATIENT,3,ML,21.79,13.074,,18.52,85,,14.816,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.66,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,114.06,31.95,,306.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.28,38,,90.592,percent of total billed charges,38% of total billed charges,6.96,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,3444.94,5096,
levalbuterol 0.63 mg/3 mL Inh Sol [FMC],4169090,CDM,250,RC,J7614,HCPCS,OUTPATIENT,3,ML,21.77,13.062,,18.5,85,,14.8,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.65,35.15,,36.808,percent of total billed charges,35.15% of total billed charges,114.06,31.95,,36.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.27,38,,90.592,percent of total billed charges,38% of total billed charges,6.96,31.95,,46.08,percent of total billed charges,31.95% of total billed charges,3445.94,5097,
levalbuterol 0.63 mg/3 mL Inh Sol [FMC],4169090,CDM,250,RC,J7614,HCPCS,OUTPATIENT,3,ML,20.92,12.552,,17.78,85,,14.224,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.35,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,115.02,31.95,,171.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.95,38,,130.416,percent of total billed charges,38% of total billed charges,6.68,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,3446.94,5098,
levalbuterol 0.63 mg/3 mL Inh Sol [FMC],4169090,CDM,250,RC,J7614,HCPCS,OUTPATIENT,3,ML,15.42,9.252,,13.11,85,,10.488,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,5.42,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,115.98,31.95,,171.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.86,38,,130.416,percent of total billed charges,38% of total billed charges,4.93,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,3447.94,5099,
levalbuterol 0.63 mg/3 mL Inh Sol [FMC],4169090,CDM,250,RC,J7614,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.08,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,8.432,percent of total billed charges,35.15% of total billed charges,117.61,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,90.592,percent of total billed charges,38% of total billed charges,3.83,31.95,,10.56,percent of total billed charges,31.95% of total billed charges,3448.94,5100,
albuterol 0.083% Inh Sol 2.5mg/3 mL [FMC],4178984,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,10.224,percent of total billed charges,35.15% of total billed charges,119.17,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,130.416,percent of total billed charges,38% of total billed charges,3.83,31.95,,12.8,percent of total billed charges,31.95% of total billed charges,3449.94,5101,
albuterol 0.083% Inh Sol 2.5mg/3 mL [FMC],4178984,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,125.248,percent of total billed charges,35.15% of total billed charges,119.17,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,130.416,percent of total billed charges,38% of total billed charges,3.83,31.95,,156.8,percent of total billed charges,31.95% of total billed charges,3450.94,5102,
albuterol 0.083% Inh Sol 2.5mg/3 mL [FMC],4178984,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,5.112,percent of total billed charges,35.15% of total billed charges,119.81,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,120.688,percent of total billed charges,38% of total billed charges,3.83,31.95,,6.4,percent of total billed charges,31.95% of total billed charges,3451.94,5103,
albuterol 0.083% Inh Sol 2.5mg/3 mL [FMC],4178984,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,12.784,percent of total billed charges,35.15% of total billed charges,120.13,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,90.592,percent of total billed charges,38% of total billed charges,3.83,31.95,,16,percent of total billed charges,31.95% of total billed charges,3452.94,5104,
albuterol 0.083% Inh Sol 2.5mg/3 mL [FMC],4178984,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,120.68,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,97.28,percent of total billed charges,38% of total billed charges,3.83,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,3453.94,5105,
albuterol 0.083% Inh Sol 2.5mg/3 mL [FMC],4178984,CDM,250,RC,J7613,HCPCS,OUTPATIENT,3,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,12.14,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,90.592,percent of total billed charges,38% of total billed charges,3.83,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,3454.94,5106,
"RT HGB Methemoglobin, Quant Charge",4178992,CDM,301,RC,82820,HCPCS,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,46.58,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,46.58,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.22,110,,1358.2,fee schedule,110% of LA custom fee schedule,12.93,100,,5.968,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,22.04,38,,12.816,percent of total billed charges,38% of total billed charges,12.93,100,,1234.552,Fee Schedule,100% of LA custom fee schedule,3455.94,5107,
racepinephrine 2.25% Inh Sol UD [FMC],4179057,CDM,250,RC,,,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,12.816,percent of total billed charges,38% of total billed charges,4.8,40,,174.4,percent of total billed charges,40% of total billed charges,3456.94,5108,
racepinephrine 2.25% Inh Sol UD [FMC],4179057,CDM,250,RC,,,OUTPATIENT,1,ML,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,12.816,percent of total billed charges,38% of total billed charges,4.8,40,,174.4,percent of total billed charges,40% of total billed charges,3457.94,5109,
STAT CHECK CO2 INDICATOR,4200003,CDM,270,RC,,,OUTPATIENT,,,26.8,16.08,,22.78,85,,18.224,Percent of total billed charges,85% of total billed charges,13.4,50,,10.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.4,50,,10.72,percent of total billed charges,50% of total billed charges,8.56,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,8.56,31.95,,25.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.18,38,,12.816,percent of total billed charges,38% of total billed charges,10.72,40,,76.68,percent of total billed charges,40% of total billed charges,3458.94,5110,
ERASER PENCIL,4200004,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,899.84,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,554.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,12.816,percent of total billed charges,38% of total billed charges,15.2,40,,817.92,percent of total billed charges,40% of total billed charges,3459.94,5111,
Oxygen Hours,4200006,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,39.368,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,12.816,percent of total billed charges,38% of total billed charges,8,40,,35.784,percent of total billed charges,40% of total billed charges,3460.94,5112,
"NASAL MASK, SMALL W/HEADGEAR",4200025,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,36.56,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,14.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,12.816,percent of total billed charges,38% of total billed charges,18.4,40,,33.232,percent of total billed charges,40% of total billed charges,3461.94,5113,
PERCENT OXYGEN MASK ADULT,4200028,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,36.56,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,16.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,12.816,percent of total billed charges,38% of total billed charges,2.4,40,,33.232,percent of total billed charges,40% of total billed charges,3462.94,5114,
PEDIATRIC 02 MASK,4200029,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,36.56,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,8.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,52.896,percent of total billed charges,38% of total billed charges,1.6,40,,33.232,percent of total billed charges,40% of total billed charges,3463.94,5115,
INKJET CARTRIDGE HP78,4200031,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,109.384,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,10.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,7.48,percent of total billed charges,38% of total billed charges,10,40,,99.432,percent of total billed charges,40% of total billed charges,3464.94,5116,
EXTRA LARGE NON VENTED FULL BIPAP MASK,4200042,CDM,270,RC,,,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,29.71,31.95,,168.72,percent of total billed charges,31.95% of total billed charges,29.71,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.34,38,,69.92,percent of total billed charges,38% of total billed charges,37.2,40,,153.36,percent of total billed charges,40% of total billed charges,3465.94,5117,
MEDIUM NON-VENTED FULL BIPAP MASK,4200044,CDM,270,RC,,,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,29.07,31.95,,196.84,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.58,38,,96.976,percent of total billed charges,38% of total billed charges,36.4,40,,178.92,percent of total billed charges,40% of total billed charges,3466.94,5118,
SMALL NON-VENTED FULL BIPAP MASK,4200045,CDM,270,RC,,,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,29.07,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.58,38,,79.952,percent of total billed charges,38% of total billed charges,36.4,40,,320,percent of total billed charges,40% of total billed charges,3467.94,5119,
LARGE NON-VENTED FULL BIPAP MASK,4200046,CDM,270,RC,,,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,29.07,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.58,38,,69.92,percent of total billed charges,38% of total billed charges,36.4,40,,76.8,percent of total billed charges,40% of total billed charges,3468.94,5120,
SMALL BI-PAP MASK,4200049,CDM,270,RC,,,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37,50,,29.6,percent of total billed charges,50% of total billed charges,23.64,31.95,,35.152,percent of total billed charges,31.95% of total billed charges,23.64,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.12,38,,52.896,percent of total billed charges,38% of total billed charges,29.6,40,,31.952,percent of total billed charges,40% of total billed charges,3469.94,5121,
BI-PAP CIRCUIT,4200050,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,79.04,percent of total billed charges,38% of total billed charges,13.2,40,,555.928,percent of total billed charges,40% of total billed charges,3470.94,5122,
EASY CAP II CO2 DETECTOR,4200051,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,69.92,percent of total billed charges,38% of total billed charges,15.2,40,,555.928,percent of total billed charges,40% of total billed charges,3471.94,5123,
THOMAS ENDO TUBE HOLDER,4200052,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,79.952,percent of total billed charges,38% of total billed charges,6.4,40,,70.288,percent of total billed charges,40% of total billed charges,3472.94,5124,
SMALL SIZE A NON-VENTED NASAL BIPAP MASK,4200053,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,7.48,percent of total billed charges,38% of total billed charges,36,40,,70.288,percent of total billed charges,40% of total billed charges,3473.94,5125,
LARGE SIZE C NON VENTED NASAL BIPAP MASK,4200055,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,52.896,percent of total billed charges,38% of total billed charges,36,40,,70.288,percent of total billed charges,40% of total billed charges,3474.94,5126,
WHISPER SWIVEL VALVE,4200078,CDM,270,RC,,,OUTPATIENT,,,70.11,42.066,,59.59,85,,47.672,Percent of total billed charges,85% of total billed charges,35.06,50,,28.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.06,50,,28.048,percent of total billed charges,50% of total billed charges,22.4,31.95,,1560.664,percent of total billed charges,31.95% of total billed charges,22.4,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.64,38,,7.48,percent of total billed charges,38% of total billed charges,28.04,40,,1418.584,percent of total billed charges,40% of total billed charges,3475.94,5127,
NEEDLE 22G X 1'''' BUTTERFLY,4200079,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,7.48,percent of total billed charges,38% of total billed charges,5.6,40,,555.928,percent of total billed charges,40% of total billed charges,3476.94,5128,
OPTIRAY 320 50ML BOTTLE,4200084,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,650,390,,682.5,105,,,case rate,pays based on 105% of threshold rate,325,50,,260,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,325,50,,260,percent of total billed charges,50% of total billed charges,228.48,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,12.42,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,247,38,,7.48,percent of total billed charges,38% of total billed charges,207.68,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,3477.94,5129,
FMC OPTIRAY 320 CT CONTRAST,4200084,CDM,278,RC,Q9967,HCPCS,OUTPATIENT,,,5,3,,5.25,105,,,case rate,pays based on 105% of threshold rate,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1.76,35.15,,208.088,percent of total billed charges,35.15% of total billed charges,12.42,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,7.48,percent of total billed charges,38% of total billed charges,1.6,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,3478.94,5130,
BATTERY SIZE AA,4200086,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,72.656,percent of total billed charges,38% of total billed charges,0.4,40,,4,percent of total billed charges,40% of total billed charges,3479.94,5131,
SCALPEL BLADE #11,4200089,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,717.064,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,7.48,percent of total billed charges,38% of total billed charges,2,40,,651.784,percent of total billed charges,40% of total billed charges,3480.94,5132,
LIGACLIP EXTRA LIGATING CLIPS,4200091,CDM,270,RC,,,OUTPATIENT,,,19.12,11.472,,16.25,85,,13,Percent of total billed charges,85% of total billed charges,9.56,50,,7.648,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.56,50,,7.648,percent of total billed charges,50% of total billed charges,6.11,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,6.11,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.27,38,,7.48,percent of total billed charges,38% of total billed charges,7.65,40,,498.424,percent of total billed charges,40% of total billed charges,3481.94,5133,
CENTRAL LINE DRESSING TRAY,4200092,CDM,270,RC,,,OUTPATIENT,,,13.76,8.256,,11.7,85,,9.36,Percent of total billed charges,85% of total billed charges,6.88,50,,5.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.88,50,,5.504,percent of total billed charges,50% of total billed charges,4.4,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,4.4,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.23,38,,14.272,percent of total billed charges,38% of total billed charges,5.5,40,,1035.184,percent of total billed charges,40% of total billed charges,3482.94,5134,
DISPOSABLE SHEETS,4200093,CDM,270,RC,,,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,59,50,,47.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,59,50,,47.2,percent of total billed charges,50% of total billed charges,37.7,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,37.7,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.84,38,,100.928,percent of total billed charges,38% of total billed charges,47.2,40,,121.6,percent of total billed charges,40% of total billed charges,3483.94,5135,
NAIL POLISH REMOVER,4200094,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,100.928,percent of total billed charges,38% of total billed charges,0.4,40,,555.928,percent of total billed charges,40% of total billed charges,3484.94,5136,
DRAPE CENTRAL LINE,4200098,CDM,270,RC,,,OUTPATIENT,,,66.68,40.008,,56.68,85,,45.344,Percent of total billed charges,85% of total billed charges,33.34,50,,26.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.34,50,,26.672,percent of total billed charges,50% of total billed charges,21.3,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,21.3,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.34,38,,14.272,percent of total billed charges,38% of total billed charges,26.67,40,,70.288,percent of total billed charges,40% of total billed charges,3485.94,5137,
STORAGE BIN SMALL 3H X 4.18W X 7.18D CLEAR,4200099,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,14.272,percent of total billed charges,38% of total billed charges,5.6,40,,70.288,percent of total billed charges,40% of total billed charges,3486.94,5138,
PROBE ELECTROHYDRAULIC 7FRX50C,4200100,CDM,270,RC,,,OUTPATIENT,,,420.13,252.078,,357.11,85,,285.688,Percent of total billed charges,85% of total billed charges,210.07,50,,168.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,210.07,50,,168.056,percent of total billed charges,50% of total billed charges,134.23,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,134.23,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,159.65,38,,14.272,percent of total billed charges,38% of total billed charges,168.05,40,,70.288,percent of total billed charges,40% of total billed charges,3487.94,5139,
EXAM TABLE PAPER,4200101,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,1560.664,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,14.272,percent of total billed charges,38% of total billed charges,6,40,,1418.584,percent of total billed charges,40% of total billed charges,3488.94,5140,
PROBE ELECTROHYDRAULIC 3FRX220,4200102,CDM,270,RC,,,OUTPATIENT,,,420.13,252.078,,357.11,85,,285.688,Percent of total billed charges,85% of total billed charges,210.07,50,,168.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,210.07,50,,168.056,percent of total billed charges,50% of total billed charges,134.23,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,134.23,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,159.65,38,,14.272,percent of total billed charges,38% of total billed charges,168.05,40,,555.928,percent of total billed charges,40% of total billed charges,3489.94,5141,
DURASPHERE EXP 1ML SYRINGE,4200105,CDM,270,RC,,,OUTPATIENT,,,337.5,202.5,,286.88,85,,229.504,Percent of total billed charges,85% of total billed charges,168.75,50,,135,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,168.75,50,,135,percent of total billed charges,50% of total billed charges,107.83,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,107.83,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.25,38,,14.272,percent of total billed charges,38% of total billed charges,135,40,,555.928,percent of total billed charges,40% of total billed charges,3490.94,5142,
INTRODUCER TRACH TUBE (BOUGIE),4200106,CDM,270,RC,,,OUTPATIENT,,,53.22,31.932,,45.24,85,,36.192,Percent of total billed charges,85% of total billed charges,26.61,50,,21.288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.61,50,,21.288,percent of total billed charges,50% of total billed charges,17,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,17,31.95,,5.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.22,38,,14.272,percent of total billed charges,38% of total billed charges,21.29,40,,70.288,percent of total billed charges,40% of total billed charges,3491.94,5143,
PLUROGEL BURN AND WOUND DRESSING 1.75OZ TUBE,4200107,CDM,270,RC,,,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,77.328,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,14.272,percent of total billed charges,38% of total billed charges,80,40,,70.288,percent of total billed charges,40% of total billed charges,3492.94,5144,
NASOPHARYNGEAL AIRWAY 12FR,4200108,CDM,270,RC,,,OUTPATIENT,,,10.02,6.012,,8.52,85,,6.816,Percent of total billed charges,85% of total billed charges,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,3.2,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,6.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.81,38,,14.272,percent of total billed charges,38% of total billed charges,4.01,40,,555.928,percent of total billed charges,40% of total billed charges,3493.94,5145,
NASOPHARYNGEAL AIRWAY 14FR,4200109,CDM,270,RC,,,OUTPATIENT,,,10.02,6.012,,8.52,85,,6.816,Percent of total billed charges,85% of total billed charges,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,3.2,31.95,,111.64,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,6.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.81,38,,14.272,percent of total billed charges,38% of total billed charges,4.01,40,,101.472,percent of total billed charges,40% of total billed charges,3494.94,5146,
NASOPHARYNGEAL AIRWAY 16FR,4200110,CDM,270,RC,,,OUTPATIENT,,,10.02,6.012,,8.52,85,,6.816,Percent of total billed charges,85% of total billed charges,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,3.2,31.95,,111.072,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,6.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.81,38,,14.272,percent of total billed charges,38% of total billed charges,4.01,40,,100.96,percent of total billed charges,40% of total billed charges,3495.94,5147,
NASOPHARYNGEAL AIRWAY 18FR,4200112,CDM,270,RC,,,OUTPATIENT,,,10.02,6.012,,8.52,85,,6.816,Percent of total billed charges,85% of total billed charges,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,3.2,31.95,,413.368,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,6.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.81,38,,14.272,percent of total billed charges,38% of total billed charges,4.01,40,,375.736,percent of total billed charges,40% of total billed charges,3496.94,5148,
NASOPHARYNGEAL AIRWAY 20FR,4200113,CDM,270,RC,,,OUTPATIENT,,,10.02,6.012,,8.52,85,,6.816,Percent of total billed charges,85% of total billed charges,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,3.2,31.95,,618.64,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.81,38,,14.272,percent of total billed charges,38% of total billed charges,4.01,40,,562.32,percent of total billed charges,40% of total billed charges,3497.94,5149,
NASOPHARYNGEAL AIRWAY 22FR,4200114,CDM,270,RC,,,OUTPATIENT,,,10.02,6.012,,8.52,85,,6.816,Percent of total billed charges,85% of total billed charges,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.01,50,,4.008,percent of total billed charges,50% of total billed charges,3.2,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,9.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.81,38,,14.272,percent of total billed charges,38% of total billed charges,4.01,40,,498.424,percent of total billed charges,40% of total billed charges,3498.94,5150,
STAPLER LINEAR 60MM PROXI,4200116,CDM,270,RC,,,OUTPATIENT,,,236,141.6,,200.6,85,,160.48,Percent of total billed charges,85% of total billed charges,118,50,,94.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,118,50,,94.4,percent of total billed charges,50% of total billed charges,75.4,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,75.4,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,89.68,38,,14.272,percent of total billed charges,38% of total billed charges,94.4,40,,9.6,percent of total billed charges,40% of total billed charges,3499.94,5151,
NEEDLE 25G X 5/8'''',4200117,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,436.424,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,14.272,percent of total billed charges,38% of total billed charges,18.8,40,,396.688,percent of total billed charges,40% of total billed charges,3500.94,5152,
NEEDLE 25G X 1'''',4200118,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,140.6,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,14.272,percent of total billed charges,38% of total billed charges,18.8,40,,127.8,percent of total billed charges,40% of total billed charges,3501.94,5153,
NEEDLE 23G X 1'''',4200119,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,99.824,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,14.272,percent of total billed charges,38% of total billed charges,18.8,40,,90.736,percent of total billed charges,40% of total billed charges,3502.94,5154,
NEEDLE BLUNT FILL,4200120,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,14.272,percent of total billed charges,38% of total billed charges,13.2,40,,1035.184,percent of total billed charges,40% of total billed charges,3503.94,5155,
NEEDLE 22G X 1.5'''',4200121,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,14.272,percent of total billed charges,38% of total billed charges,18.8,40,,498.424,percent of total billed charges,40% of total billed charges,3504.94,5156,
SINGLE TRANSDUCER 60'''' PRESSURE TUBING,4200122,CDM,270,RC,,,OUTPATIENT,,,84,50.4,,71.4,85,,57.12,Percent of total billed charges,85% of total billed charges,42,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42,50,,33.6,percent of total billed charges,50% of total billed charges,26.84,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,26.84,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.92,38,,14.272,percent of total billed charges,38% of total billed charges,33.6,40,,121.6,percent of total billed charges,40% of total billed charges,3505.94,5157,
"TWO TRANSDUCER, TWO LINES, 60'''' TUBING",4200123,CDM,270,RC,,,OUTPATIENT,,,1215,729,,1032.75,85,,826.2,Percent of total billed charges,85% of total billed charges,607.5,50,,486,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,607.5,50,,486,percent of total billed charges,50% of total billed charges,388.19,31.95,,99.824,percent of total billed charges,31.95% of total billed charges,388.19,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,461.7,38,,14.272,percent of total billed charges,38% of total billed charges,486,40,,90.736,percent of total billed charges,40% of total billed charges,3506.94,5158,
NEEDLE BLUNT FILTER,4200124,CDM,270,RC,,,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33,50,,26.4,percent of total billed charges,50% of total billed charges,21.09,31.95,,111.64,percent of total billed charges,31.95% of total billed charges,21.09,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.08,38,,14.272,percent of total billed charges,38% of total billed charges,26.4,40,,101.472,percent of total billed charges,40% of total billed charges,3507.94,5159,
NEEDLE 18G 1 1/2,4200125,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,3.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,77.216,percent of total billed charges,38% of total billed charges,18.8,40,,460.08,percent of total billed charges,40% of total billed charges,3508.94,5160,
DURASPHERE EXP 3ML SYRINGE,4200126,CDM,270,RC,,,OUTPATIENT,,,1012.5,607.5,,860.63,85,,688.504,Percent of total billed charges,85% of total billed charges,506.25,50,,405,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,506.25,50,,405,percent of total billed charges,50% of total billed charges,323.49,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,323.49,31.95,,3.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,384.75,38,,77.216,percent of total billed charges,38% of total billed charges,405,40,,421.744,percent of total billed charges,40% of total billed charges,3509.94,5161,
PUNCH BIOPSY 2MM DISPOSABLE,4200129,CDM,270,RC,,,OUTPATIENT,,,7.79,4.674,,6.62,85,,5.296,Percent of total billed charges,85% of total billed charges,3.9,50,,3.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.9,50,,3.12,percent of total billed charges,50% of total billed charges,2.49,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,2.49,31.95,,3.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.96,38,,77.216,percent of total billed charges,38% of total billed charges,3.12,40,,1035.184,percent of total billed charges,40% of total billed charges,3510.94,5162,
PUNCH BIOPSY 3MM DISPOSABLE,4200130,CDM,270,RC,,,OUTPATIENT,,,8.28,4.968,,7.04,85,,5.632,Percent of total billed charges,85% of total billed charges,4.14,50,,3.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.14,50,,3.312,percent of total billed charges,50% of total billed charges,2.65,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,2.65,31.95,,3.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.15,38,,7.752,percent of total billed charges,38% of total billed charges,3.31,40,,498.424,percent of total billed charges,40% of total billed charges,3511.94,5163,
CUTTING LOOP 24FR,4200131,CDM,270,RC,,,OUTPATIENT,,,480,288,,408,85,,326.4,Percent of total billed charges,85% of total billed charges,240,50,,192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,240,50,,192,percent of total billed charges,50% of total billed charges,153.36,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,153.36,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,182.4,38,,7.752,percent of total billed charges,38% of total billed charges,192,40,,126.4,percent of total billed charges,40% of total billed charges,3512.94,5164,
BLADE LARYNGOSCOPE DISPOSABLE MILLER 3 LED,4200133,CDM,272,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,96.36,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,96.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,7.752,percent of total billed charges,38% of total billed charges,16,40,,120.64,percent of total billed charges,40% of total billed charges,3513.94,5165,
TRAY ANESTHESIA SPINAL PENCAN 25GX3.5,4200134,CDM,272,RC,,,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40,50,,32,percent of total billed charges,50% of total billed charges,25.56,31.95,,12.936,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.4,38,,7.752,percent of total billed charges,38% of total billed charges,32,40,,11.76,percent of total billed charges,40% of total billed charges,3514.94,5166,
GOWN SURGICAL 2X-LARGE X-LONG STERILE,4200135,CDM,272,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,140.6,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,3.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,7.752,percent of total billed charges,38% of total billed charges,6.8,40,,127.8,percent of total billed charges,40% of total billed charges,3515.94,5167,
DUAL SWAB CAP (BLUE/WHITE),4200136,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,3.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,7.752,percent of total billed charges,38% of total billed charges,0.8,40,,498.424,percent of total billed charges,40% of total billed charges,3516.94,5168,
INFOVAC CANISTER WITH GEL,4200137,CDM,270,RC,,,OUTPATIENT,,,123.64,74.184,,105.09,85,,84.072,Percent of total billed charges,85% of total billed charges,61.82,50,,49.456,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,61.82,50,,49.456,percent of total billed charges,50% of total billed charges,39.5,31.95,,113.608,percent of total billed charges,31.95% of total billed charges,39.5,31.95,,3.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.98,38,,7.752,percent of total billed charges,38% of total billed charges,49.46,40,,103.264,percent of total billed charges,40% of total billed charges,3517.94,5169,
SENSATRAC PAD,4200138,CDM,270,RC,,,OUTPATIENT,,,56.95,34.17,,48.41,85,,38.728,Percent of total billed charges,85% of total billed charges,28.48,50,,22.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.48,50,,22.784,percent of total billed charges,50% of total billed charges,18.2,31.95,,149.04,percent of total billed charges,31.95% of total billed charges,18.2,31.95,,4.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.64,38,,7.752,percent of total billed charges,38% of total billed charges,22.78,40,,135.472,percent of total billed charges,40% of total billed charges,3518.94,5170,
ABTHERA DRESSING,4200140,CDM,270,RC,,,OUTPATIENT,,,543.38,326.028,,461.87,85,,369.496,Percent of total billed charges,85% of total billed charges,271.69,50,,217.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,271.69,50,,217.352,percent of total billed charges,50% of total billed charges,173.61,31.95,,149.04,percent of total billed charges,31.95% of total billed charges,173.61,31.95,,5.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,206.48,38,,7.752,percent of total billed charges,38% of total billed charges,217.35,40,,135.472,percent of total billed charges,40% of total billed charges,3519.94,5171,
GOWN SURGICAL LARGE,4200143,CDM,272,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,30.368,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,6.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,7.752,percent of total billed charges,38% of total billed charges,7.2,40,,27.608,percent of total billed charges,40% of total billed charges,3520.94,5172,
"BRAVO BUFFER, PH 1.07",4200144,CDM,272,RC,,,OUTPATIENT,,,88,52.8,,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44,50,,35.2,percent of total billed charges,50% of total billed charges,28.12,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,28.12,31.95,,23.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.44,38,,7.752,percent of total billed charges,38% of total billed charges,35.2,40,,920.16,percent of total billed charges,40% of total billed charges,3521.94,5173,
"BRAVO BUFFER, PH 7.01",4200145,CDM,272,RC,,,OUTPATIENT,,,88,52.8,,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44,50,,35.2,percent of total billed charges,50% of total billed charges,28.12,31.95,,306.512,percent of total billed charges,31.95% of total billed charges,28.12,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.44,38,,7.752,percent of total billed charges,38% of total billed charges,35.2,40,,278.608,percent of total billed charges,40% of total billed charges,3522.94,5174,
NEEDLE EXP SPINAL TIP 1.5'''',4200147,CDM,270,RC,,,OUTPATIENT,,,84,50.4,,71.4,85,,57.12,Percent of total billed charges,85% of total billed charges,42,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42,50,,33.6,percent of total billed charges,50% of total billed charges,26.84,31.95,,884.376,percent of total billed charges,31.95% of total billed charges,26.84,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.92,38,,7.752,percent of total billed charges,38% of total billed charges,33.6,40,,803.864,percent of total billed charges,40% of total billed charges,3523.94,5175,
NEEDLE EXP SPINAL TIP 15'''',4200148,CDM,270,RC,,,OUTPATIENT,,,84,50.4,,71.4,85,,57.12,Percent of total billed charges,85% of total billed charges,42,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42,50,,33.6,percent of total billed charges,50% of total billed charges,26.84,31.95,,109.384,percent of total billed charges,31.95% of total billed charges,26.84,31.95,,46.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.92,38,,7.752,percent of total billed charges,38% of total billed charges,33.6,40,,99.432,percent of total billed charges,40% of total billed charges,3524.94,5176,
DISK BIOPATCH STERILE 1,4200150,CDM,270,RC,A4221,HCPCS,OUTPATIENT,,,29.26,17.556,,24.87,85,,19.896,Percent of total billed charges,85% of total billed charges,14.63,50,,11.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.63,50,,11.704,percent of total billed charges,50% of total billed charges,10.28,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,12.42,31.95,,7.864,percent of total billed charges,31.95% of total billed charges,24.46,100,,,fee schedule,100% of CMS custom fee schedule,11.12,38,,7.752,percent of total billed charges,38% of total billed charges,9.35,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,3525.94,5177,
BOUFFANT CAPS 21'''' REGULAR,4200151,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,109.384,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,7.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,7.752,percent of total billed charges,38% of total billed charges,7.2,40,,99.432,percent of total billed charges,40% of total billed charges,3526.94,5178,
OSTOMY PASTE STOMAHESIVE 2OZ,4200152,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,109.384,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,9.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,7.752,percent of total billed charges,38% of total billed charges,5,40,,99.432,percent of total billed charges,40% of total billed charges,3527.94,5179,
DISK BIOPATCH STERILE 3/4'''',4200153,CDM,270,RC,A4221,HCPCS,OUTPATIENT,,,32.44,19.464,,27.57,85,,22.056,Percent of total billed charges,85% of total billed charges,16.22,50,,12.976,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.22,50,,12.976,percent of total billed charges,50% of total billed charges,11.4,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,12.42,31.95,,12.464,percent of total billed charges,31.95% of total billed charges,24.46,100,,,fee schedule,100% of CMS custom fee schedule,12.33,38,,7.752,percent of total billed charges,38% of total billed charges,10.36,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,3528.94,5180,
DEFIBRILLATION PAD PEDI (M3719A),4200155,CDM,270,RC,,,OUTPATIENT,,,73.44,44.064,,62.42,85,,49.936,Percent of total billed charges,85% of total billed charges,36.72,50,,29.376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36.72,50,,29.376,percent of total billed charges,50% of total billed charges,23.46,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,23.46,31.95,,30.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.91,38,,7.752,percent of total billed charges,38% of total billed charges,29.38,40,,498.424,percent of total billed charges,40% of total billed charges,3529.94,5181,
COILED TUBING 60'''',4200157,CDM,270,RC,,,OUTPATIENT,,,7.21,4.326,,6.13,85,,4.904,Percent of total billed charges,85% of total billed charges,3.61,50,,2.888,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.61,50,,2.888,percent of total billed charges,50% of total billed charges,2.3,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,2.3,31.95,,30.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.74,38,,7.752,percent of total billed charges,38% of total billed charges,2.88,40,,690.12,percent of total billed charges,40% of total billed charges,3530.94,5182,
QUICKCLOT EMERGENCY DRESSING W/XRAY,4200158,CDM,270,RC,,,OUTPATIENT,,,103,61.8,,87.55,85,,70.04,Percent of total billed charges,85% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,32.91,31.95,,379.624,percent of total billed charges,31.95% of total billed charges,32.91,31.95,,65.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.14,38,,7.752,percent of total billed charges,38% of total billed charges,41.2,40,,345.064,percent of total billed charges,40% of total billed charges,3531.94,5183,
AQUACEL AG EXTRA HYDROFIBER DRESSING 4X5,4200159,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,281.2,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,7.752,percent of total billed charges,38% of total billed charges,8,40,,255.6,percent of total billed charges,40% of total billed charges,3532.94,5184,
SIGMOIDOSCOPE DISPOSABLE COVER,4200160,CDM,270,RC,,,OUTPATIENT,,,15.88,9.528,,13.5,85,,10.8,Percent of total billed charges,85% of total billed charges,7.94,50,,6.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.94,50,,6.352,percent of total billed charges,50% of total billed charges,5.07,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,5.07,31.95,,4.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.03,38,,7.752,percent of total billed charges,38% of total billed charges,6.35,40,,78.728,percent of total billed charges,40% of total billed charges,3533.94,5185,
T-TUBE DEAVER 5'''' CROSSBAR 8FR,4200163,CDM,270,RC,,,OUTPATIENT,,,30.13,18.078,,25.61,85,,20.488,Percent of total billed charges,85% of total billed charges,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,9.63,31.95,,95.608,percent of total billed charges,31.95% of total billed charges,9.63,31.95,,4.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.45,38,,100.928,percent of total billed charges,38% of total billed charges,12.05,40,,86.904,percent of total billed charges,40% of total billed charges,3534.94,5186,
T-TUBE DEAVER 5'''' CROSSBAR 10FR,4200164,CDM,270,RC,,,OUTPATIENT,,,30.13,18.078,,25.61,85,,20.488,Percent of total billed charges,85% of total billed charges,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,9.63,31.95,,1034.816,percent of total billed charges,31.95% of total billed charges,9.63,31.95,,6.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.45,38,,134.672,percent of total billed charges,38% of total billed charges,12.05,40,,940.608,percent of total billed charges,40% of total billed charges,3535.94,5187,
T-TUBE DEAVER 5'''' CROSSBAR 12FR,4200165,CDM,270,RC,,,OUTPATIENT,,,30.13,18.078,,25.61,85,,20.488,Percent of total billed charges,85% of total billed charges,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,9.63,31.95,,105.448,percent of total billed charges,31.95% of total billed charges,9.63,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.45,38,,134.672,percent of total billed charges,38% of total billed charges,12.05,40,,95.848,percent of total billed charges,40% of total billed charges,3536.94,5188,
T-TUBE DEAVER 5'''' CROSSBAR 14FR,4200166,CDM,270,RC,,,OUTPATIENT,,,30.13,18.078,,25.61,85,,20.488,Percent of total billed charges,85% of total billed charges,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,9.63,31.95,,89.984,percent of total billed charges,31.95% of total billed charges,9.63,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.45,38,,134.672,percent of total billed charges,38% of total billed charges,12.05,40,,81.792,percent of total billed charges,40% of total billed charges,3537.94,5189,
T-TUBE DEAVER 5'''' CROSSBAR 16FR,4200167,CDM,270,RC,,,OUTPATIENT,,,30.13,18.078,,25.61,85,,20.488,Percent of total billed charges,85% of total billed charges,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,9.63,31.95,,104.8,percent of total billed charges,31.95% of total billed charges,9.63,31.95,,104.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.45,38,,165.68,percent of total billed charges,38% of total billed charges,12.05,40,,131.2,percent of total billed charges,40% of total billed charges,3538.94,5190,
T-TUBE DEAVER 5'''' CROSSBAR 18FR,4200168,CDM,270,RC,,,OUTPATIENT,,,30.13,18.078,,25.61,85,,20.488,Percent of total billed charges,85% of total billed charges,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,9.63,31.95,,70.304,percent of total billed charges,31.95% of total billed charges,9.63,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.45,38,,138.016,percent of total billed charges,38% of total billed charges,12.05,40,,63.904,percent of total billed charges,40% of total billed charges,3539.94,5191,
T-TUBE DEAVER 5'''' CROSSBAR 20FR,4200169,CDM,270,RC,,,OUTPATIENT,,,30.13,18.078,,25.61,85,,20.488,Percent of total billed charges,85% of total billed charges,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.07,50,,12.056,percent of total billed charges,50% of total billed charges,9.63,31.95,,112.48,percent of total billed charges,31.95% of total billed charges,9.63,31.95,,3.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.45,38,,152,percent of total billed charges,38% of total billed charges,12.05,40,,102.24,percent of total billed charges,40% of total billed charges,3540.94,5192,
TRIPLE LUMEN 7FR 20CM CENTRAL LINE KIT,4200175,CDM,270,RC,,,OUTPATIENT,,,462,277.2,,392.7,85,,314.16,Percent of total billed charges,85% of total billed charges,231,50,,184.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,231,50,,184.8,percent of total billed charges,50% of total billed charges,147.61,31.95,,111.072,percent of total billed charges,31.95% of total billed charges,147.61,31.95,,3.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175.56,38,,100.928,percent of total billed charges,38% of total billed charges,184.8,40,,100.96,percent of total billed charges,40% of total billed charges,3541.94,5193,
VALVE ULTRASITE,4200176,CDM,270,RC,,,OUTPATIENT,,,4.15,2.49,,3.53,85,,2.824,Percent of total billed charges,85% of total billed charges,2.08,50,,1.664,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.08,50,,1.664,percent of total billed charges,50% of total billed charges,1.33,31.95,,98.424,percent of total billed charges,31.95% of total billed charges,1.33,31.95,,4.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.58,38,,152,percent of total billed charges,38% of total billed charges,1.66,40,,89.464,percent of total billed charges,40% of total billed charges,3542.94,5194,
SUTURE 0.0 URO CTD VICRYL O TIE,4200177,CDM,270,RC,,,OUTPATIENT,,,8.96,5.376,,7.62,85,,6.096,Percent of total billed charges,85% of total billed charges,4.48,50,,3.584,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.48,50,,3.584,percent of total billed charges,50% of total billed charges,2.86,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,2.86,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.4,38,,152,percent of total billed charges,38% of total billed charges,3.58,40,,4,percent of total billed charges,40% of total billed charges,3543.94,5195,
SUTURE LOADING UNIT ENDO STITCH 2.0,4200178,CDM,270,RC,,,OUTPATIENT,,,357.18,214.308,,303.6,85,,242.88,Percent of total billed charges,85% of total billed charges,178.59,50,,142.872,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,178.59,50,,142.872,percent of total billed charges,50% of total billed charges,114.12,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,114.12,31.95,,4.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.73,38,,152,percent of total billed charges,38% of total billed charges,142.87,40,,690.12,percent of total billed charges,40% of total billed charges,3544.94,5196,
SUTURE PROLENE 2.0 30 1/2 CIRCLE 36MM CT-1,4200179,CDM,278,RC,,,OUTPATIENT,,,12.5,7.5,,13.13,105,,,case rate,pays based on 105% of threshold rate,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,717.064,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,12.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,152,percent of total billed charges,38% of total billed charges,5,40,,651.784,percent of total billed charges,40% of total billed charges,3545.94,5197,
MAXORB II SILVER ALGINATE WOUND DRESSING 4 X 4.75,4200183,CDM,272,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,152,percent of total billed charges,38% of total billed charges,10,40,,185.6,percent of total billed charges,40% of total billed charges,3546.94,5198,
FEMORAL ARTERIAL LINE CATHERIZATION KIT,4200184,CDM,270,RC,,,OUTPATIENT,,,84.75,50.85,,72.04,85,,57.632,Percent of total billed charges,85% of total billed charges,42.38,50,,33.904,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.38,50,,33.904,percent of total billed charges,50% of total billed charges,27.08,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,27.08,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.21,38,,109.44,percent of total billed charges,38% of total billed charges,33.9,40,,185.6,percent of total billed charges,40% of total billed charges,3547.94,5199,
ELECTRODE EXTENSION 1'''' BLADE,4200186,CDM,270,RC,,,OUTPATIENT,,,6.03,3.618,,5.13,85,,4.104,Percent of total billed charges,85% of total billed charges,3.02,50,,2.416,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.02,50,,2.416,percent of total billed charges,50% of total billed charges,1.93,31.95,,984.2,percent of total billed charges,31.95% of total billed charges,1.93,31.95,,13.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.29,38,,100.928,percent of total billed charges,38% of total billed charges,2.41,40,,894.6,percent of total billed charges,40% of total billed charges,3548.94,5200,
TROCAR BALLOON KII 12X100MM,4200187,CDM,270,RC,,,OUTPATIENT,,,128.7,77.22,,109.4,85,,87.52,Percent of total billed charges,85% of total billed charges,64.35,50,,51.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.35,50,,51.48,percent of total billed charges,50% of total billed charges,41.12,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,41.12,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.91,38,,100.928,percent of total billed charges,38% of total billed charges,51.48,40,,421.744,percent of total billed charges,40% of total billed charges,3549.94,5201,
TROCAR ENDOPATH 75MM,4200188,CDM,270,RC,,,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,84,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84,50,,67.2,percent of total billed charges,50% of total billed charges,53.68,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.84,38,,119.168,percent of total billed charges,38% of total billed charges,67.2,40,,230.04,percent of total billed charges,40% of total billed charges,3550.94,5202,
HYPERGEL DRESSING 5GM,4200189,CDM,270,RC,,,OUTPATIENT,,,7.86,4.716,,6.68,85,,5.344,Percent of total billed charges,85% of total billed charges,3.93,50,,3.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.93,50,,3.144,percent of total billed charges,50% of total billed charges,2.51,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,2.51,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.99,38,,14.272,percent of total billed charges,38% of total billed charges,3.14,40,,498.424,percent of total billed charges,40% of total billed charges,3551.94,5203,
ENDOPATH XCEL BLADELESS TROCAR,4200190,CDM,270,RC,,,OUTPATIENT,,,179.49,107.694,,152.57,85,,122.056,Percent of total billed charges,85% of total billed charges,89.75,50,,71.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,89.75,50,,71.8,percent of total billed charges,50% of total billed charges,57.35,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,57.35,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.21,38,,100.928,percent of total billed charges,38% of total billed charges,71.8,40,,9.6,percent of total billed charges,40% of total billed charges,3552.94,5204,
SPINAL TRAY PEDIATRIC,4200191,CDM,270,RC,,,OUTPATIENT,,,42.64,25.584,,36.24,85,,28.992,Percent of total billed charges,85% of total billed charges,21.32,50,,17.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.32,50,,17.056,percent of total billed charges,50% of total billed charges,13.62,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,13.62,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.2,38,,14.272,percent of total billed charges,38% of total billed charges,17.06,40,,9.6,percent of total billed charges,40% of total billed charges,3553.94,5205,
NORMIGEL 0.17OZ,4200194,CDM,270,RC,,,OUTPATIENT,,,7.86,4.716,,6.68,85,,5.344,Percent of total billed charges,85% of total billed charges,3.93,50,,3.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.93,50,,3.144,percent of total billed charges,50% of total billed charges,2.51,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,2.51,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.99,38,,14.272,percent of total billed charges,38% of total billed charges,3.14,40,,9.6,percent of total billed charges,40% of total billed charges,3554.94,5206,
AQUACEL DRESSING HYDRFBR,4200195,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,100.928,percent of total billed charges,38% of total billed charges,2.4,40,,9.6,percent of total billed charges,40% of total billed charges,3555.94,5207,
TEMP FIX LEAD SINGLE USE,4200196,CDM,270,RC,,,OUTPATIENT,,,420,252,,357,85,,285.6,Percent of total billed charges,85% of total billed charges,210,50,,168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,210,50,,168,percent of total billed charges,50% of total billed charges,134.19,31.95,,129.352,percent of total billed charges,31.95% of total billed charges,134.19,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,159.6,38,,14.272,percent of total billed charges,38% of total billed charges,168,40,,117.576,percent of total billed charges,40% of total billed charges,3556.94,5208,
STAPLER RELOAD ENDOPATH WHITE 12MM,4200197,CDM,270,RC,,,OUTPATIENT,,,294.57,176.742,,250.38,85,,200.304,Percent of total billed charges,85% of total billed charges,147.29,50,,117.832,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,147.29,50,,117.832,percent of total billed charges,50% of total billed charges,94.12,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,94.12,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,111.94,38,,100.928,percent of total billed charges,38% of total billed charges,117.83,40,,230.04,percent of total billed charges,40% of total billed charges,3557.94,5209,
ENDOPATH XCEL BLUNT TIP TROCAR,4200198,CDM,270,RC,,,OUTPATIENT,,,158.75,95.25,,134.94,85,,107.952,Percent of total billed charges,85% of total billed charges,79.38,50,,63.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79.38,50,,63.504,percent of total billed charges,50% of total billed charges,50.72,31.95,,139.472,percent of total billed charges,31.95% of total billed charges,50.72,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.33,38,,100.928,percent of total billed charges,38% of total billed charges,63.5,40,,126.776,percent of total billed charges,40% of total billed charges,3558.94,5210,
FISTUAL NEEDLE 15G W/12 TUBING,4200199,CDM,272,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,20.248,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,14.272,percent of total billed charges,38% of total billed charges,5,40,,18.4,percent of total billed charges,40% of total billed charges,3559.94,5211,
CLAMP OCCLUDING FORCEPS,4200200,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,20.248,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,4.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,7.752,percent of total billed charges,38% of total billed charges,5,40,,18.4,percent of total billed charges,40% of total billed charges,3560.94,5212,
GLIDESCOPE STATS GVL 4,4200201,CDM,270,RC,,,OUTPATIENT,,,119.66,71.796,,101.71,85,,81.368,Percent of total billed charges,85% of total billed charges,59.83,50,,47.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,59.83,50,,47.864,percent of total billed charges,50% of total billed charges,38.23,31.95,,20.248,percent of total billed charges,31.95% of total billed charges,38.23,31.95,,29.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.47,38,,54.72,percent of total billed charges,38% of total billed charges,47.86,40,,18.4,percent of total billed charges,40% of total billed charges,3561.94,5213,
SOCK FALL MANAGEMENT LARGE,4200202,CDM,270,RC,,,OUTPATIENT,,,7.15,4.29,,6.08,85,,4.864,Percent of total billed charges,85% of total billed charges,3.58,50,,2.864,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.58,50,,2.864,percent of total billed charges,50% of total billed charges,2.28,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,2.28,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.72,38,,100.624,percent of total billed charges,38% of total billed charges,2.86,40,,121.6,percent of total billed charges,40% of total billed charges,3562.94,5214,
ZIPWIRE GUIDEWIRE .038/150 STD ANGLED TIP,4200204,CDM,270,RC,,,OUTPATIENT,,,565,339,,480.25,85,,384.2,Percent of total billed charges,85% of total billed charges,282.5,50,,226,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,282.5,50,,226,percent of total billed charges,50% of total billed charges,180.52,31.95,,36.808,percent of total billed charges,31.95% of total billed charges,180.52,31.95,,36.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,214.7,38,,82.384,percent of total billed charges,38% of total billed charges,226,40,,46.08,percent of total billed charges,40% of total billed charges,3563.94,5215,
BASKET STONE RETRIEVAL ESCAPE NITINOL,4200205,CDM,270,RC,,,OUTPATIENT,,,745,447,,633.25,85,,506.6,Percent of total billed charges,85% of total billed charges,372.5,50,,298,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,372.5,50,,298,percent of total billed charges,50% of total billed charges,238.03,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,238.03,31.95,,30.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,283.1,38,,100.32,percent of total billed charges,38% of total billed charges,298,40,,1035.184,percent of total billed charges,40% of total billed charges,3564.94,5216,
ADAPTOR GATEWAY Y,4200206,CDM,270,RC,,,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,15.66,31.95,,717.064,percent of total billed charges,31.95% of total billed charges,15.66,31.95,,18.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.62,38,,100.32,percent of total billed charges,38% of total billed charges,19.6,40,,651.784,percent of total billed charges,40% of total billed charges,3565.94,5217,
GUIDEWIRE AMPLATZ PTFE .038 FLOPPY,4200207,CDM,270,RC,,,OUTPATIENT,,,79,47.4,,67.15,85,,53.72,Percent of total billed charges,85% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,25.24,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,25.24,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.02,38,,100.32,percent of total billed charges,38% of total billed charges,31.6,40,,498.424,percent of total billed charges,40% of total billed charges,3566.94,5218,
BASKET STONE RETRIEVAL ZERO TIP NITINOL 1.9,4200208,CDM,270,RC,,,OUTPATIENT,,,615,369,,522.75,85,,418.2,Percent of total billed charges,85% of total billed charges,307.5,50,,246,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,307.5,50,,246,percent of total billed charges,50% of total billed charges,196.49,31.95,,500.536,percent of total billed charges,31.95% of total billed charges,196.49,31.95,,20.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,233.7,38,,54.72,percent of total billed charges,38% of total billed charges,246,40,,454.968,percent of total billed charges,40% of total billed charges,3567.94,5219,
FIBERS LASER FLEXIVA 365 HIGH POWER,4200209,CDM,270,RC,,,OUTPATIENT,,,950,570,,807.5,85,,646,Percent of total billed charges,85% of total billed charges,475,50,,380,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,475,50,,380,percent of total billed charges,50% of total billed charges,303.53,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,303.53,31.95,,7.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,361,38,,100.32,percent of total billed charges,38% of total billed charges,380,40,,498.424,percent of total billed charges,40% of total billed charges,3568.94,5220,
CATHETER URETERAL FLEXIMA F/G 5FR OPEN END,4200210,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,14.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,55.024,percent of total billed charges,38% of total billed charges,11.6,40,,690.12,percent of total billed charges,40% of total billed charges,3569.94,5221,
DILATOR-SHEATH SET 8/10 RD/8/10IS,4200211,CDM,270,RC,,,OUTPATIENT,,,153,91.8,,130.05,85,,104.04,Percent of total billed charges,85% of total billed charges,76.5,50,,61.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,76.5,50,,61.2,percent of total billed charges,50% of total billed charges,48.88,31.95,,717.064,percent of total billed charges,31.95% of total billed charges,48.88,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,58.14,38,,100.32,percent of total billed charges,38% of total billed charges,61.2,40,,651.784,percent of total billed charges,40% of total billed charges,3570.94,5222,
STERILE WATER 2000CC POUR,4200212,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,2556.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,100.32,percent of total billed charges,38% of total billed charges,1.2,40,,2323.912,percent of total billed charges,40% of total billed charges,3571.94,5223,
OPTIFLUX 180 DIALYZER F180NRe,4200213,CDM,270,RC,,,OUTPATIENT,,,142,85.2,,120.7,85,,96.56,Percent of total billed charges,85% of total billed charges,71,50,,56.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,71,50,,56.8,percent of total billed charges,50% of total billed charges,45.37,31.95,,1630.96,percent of total billed charges,31.95% of total billed charges,45.37,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.96,38,,82.08,percent of total billed charges,38% of total billed charges,56.8,40,,1482.48,percent of total billed charges,40% of total billed charges,3572.94,5224,
OPTIFLUX 200 DIALYZER F200NRe,4200214,CDM,270,RC,,,OUTPATIENT,,,159,95.4,,135.15,85,,108.12,Percent of total billed charges,85% of total billed charges,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,50.8,31.95,,421.8,percent of total billed charges,31.95% of total billed charges,50.8,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.42,38,,100.32,percent of total billed charges,38% of total billed charges,63.6,40,,383.4,percent of total billed charges,40% of total billed charges,3573.94,5225,
LARYNGEAL MASK 2.5,4200215,CDM,272,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,421.8,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,54.72,percent of total billed charges,38% of total billed charges,8,40,,383.4,percent of total billed charges,40% of total billed charges,3574.94,5226,
PROTECTIVE GLASSES,4200216,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,934.992,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,82.08,percent of total billed charges,38% of total billed charges,3.6,40,,849.872,percent of total billed charges,40% of total billed charges,3575.94,5227,
STENT URETERAL ULTRA POLARIS 6/28,4200217,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,439.8,percent of total billed charges,35.15% of total billed charges,12.42,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,55.024,percent of total billed charges,38% of total billed charges,137.39,31.95,,399.76,percent of total billed charges,31.95% of total billed charges,3576.94,5228,
STENT URETERAL ULTRA POLARIS 6/30,4200218,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,489.288,percent of total billed charges,35.15% of total billed charges,12.42,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,16.872,percent of total billed charges,38% of total billed charges,137.39,31.95,,444.744,percent of total billed charges,31.95% of total billed charges,3577.94,5229,
EVACUATOR BLADDER UROVAC,4200219,CDM,270,RC,,,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,49,50,,39.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,49,50,,39.2,percent of total billed charges,50% of total billed charges,31.31,31.95,,489.288,percent of total billed charges,31.95% of total billed charges,31.31,31.95,,3.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.24,38,,63.232,percent of total billed charges,38% of total billed charges,39.2,40,,444.744,percent of total billed charges,40% of total billed charges,3578.94,5230,
STENT URETERAL POLARIS ULTRA 6/20,4200220,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,95.848,percent of total billed charges,35.15% of total billed charges,121.41,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,55.024,percent of total billed charges,38% of total billed charges,137.39,31.95,,120,percent of total billed charges,31.95% of total billed charges,3579.94,5231,
THERMOSCAN PROBE COVERS,4200222,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,717.064,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,7.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,16.872,percent of total billed charges,38% of total billed charges,18.4,40,,651.784,percent of total billed charges,40% of total billed charges,3580.94,5232,
THERMOMETER RECTAL DIGITAL,4200223,CDM,270,RC,,,OUTPATIENT,,,26.56,15.936,,22.58,85,,18.064,Percent of total billed charges,85% of total billed charges,13.28,50,,10.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.28,50,,10.624,percent of total billed charges,50% of total billed charges,8.49,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,8.49,31.95,,9.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.09,38,,133.76,percent of total billed charges,38% of total billed charges,10.62,40,,498.424,percent of total billed charges,40% of total billed charges,3581.94,5233,
"THUNDERBEAT 5MM, 35CM, FRONT-ACTUATED GRIP TYPE S",4200224,CDM,270,RC,,,OUTPATIENT,,,918,550.8,,780.3,85,,624.24,Percent of total billed charges,85% of total billed charges,459,50,,367.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,459,50,,367.2,percent of total billed charges,50% of total billed charges,293.3,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,293.3,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,348.84,38,,16.872,percent of total billed charges,38% of total billed charges,367.2,40,,498.424,percent of total billed charges,40% of total billed charges,3582.94,5234,
STENT URETERAL POLARIS ULTRA 6/22,4200226,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,121.41,31.95,,3.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,54.72,percent of total billed charges,38% of total billed charges,137.39,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,3583.94,5235,
SYRINGE 10CC 18GX1 305064,4200228,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,730.56,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,3.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,16.872,percent of total billed charges,38% of total billed charges,18.8,40,,664.048,percent of total billed charges,40% of total billed charges,3584.94,5236,
SYRINGE 60CC LL 309653,4200234,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.7,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,122.69,31.95,,25.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,16.872,percent of total billed charges,38% of total billed charges,0.64,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,3585.94,5237,
FMC SYRINGE 60CC LL,4200234,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,4.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,94.24,percent of total billed charges,38% of total billed charges,0.8,40,,920.16,percent of total billed charges,40% of total billed charges,3586.94,5238,
SYRINGE 5CC 18GX1 305062,4200235,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,32.336,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,12.68,percent of total billed charges,38% of total billed charges,17.6,40,,29.392,percent of total billed charges,40% of total billed charges,3587.94,5239,
FMC SYRINGE 30CC LL,4200235,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,5.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,101.84,percent of total billed charges,38% of total billed charges,17.6,40,,920.16,percent of total billed charges,40% of total billed charges,3588.94,5240,
SYRINGE 10CC LL 309604,4200236,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,10.19,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,122.69,31.95,,5.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,73.872,percent of total billed charges,38% of total billed charges,9.27,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,3589.94,5241,
SYRINGE 3CC LL 309657,4200238,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,646.76,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,5.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,161.12,percent of total billed charges,38% of total billed charges,0.4,40,,587.88,percent of total billed charges,40% of total billed charges,3590.94,5242,
STENT URETERAL POLARIS ULTRA 6/24,4200239,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,122.69,31.95,,7.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,12.68,percent of total billed charges,38% of total billed charges,137.39,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,3591.94,5243,
STENT URETERAL POLARIS ULTRA 6/26,4200240,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,122.69,31.95,,7.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,183.92,percent of total billed charges,38% of total billed charges,137.39,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,3592.94,5244,
DUAL LUMEN URETERAL CATHETER UDC/10/50 M,4200241,CDM,270,RC,,,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,84,percent of total billed charges,50% of total billed charges,67.1,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,67.1,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.8,38,,24.896,percent of total billed charges,38% of total billed charges,84,40,,498.424,percent of total billed charges,40% of total billed charges,3593.94,5245,
FIBER DELIVERY DEVICE DUOTOME 550 MICRON,4200242,CDM,270,RC,,,OUTPATIENT,,,2470,1482,,2099.5,85,,1679.6,Percent of total billed charges,85% of total billed charges,1235,50,,988,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1235,50,,988,percent of total billed charges,50% of total billed charges,789.17,31.95,,880.16,percent of total billed charges,31.95% of total billed charges,789.17,31.95,,3.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,938.6,38,,24.896,percent of total billed charges,38% of total billed charges,988,40,,800.032,percent of total billed charges,40% of total billed charges,3594.94,5246,
FORCEPS BIOPSY URETEROSCOPE 3FR 1MM B.F.,4200243,CDM,270,RC,,,OUTPATIENT,,,972,583.2,,826.2,85,,660.96,Percent of total billed charges,85% of total billed charges,486,50,,388.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,486,50,,388.8,percent of total billed charges,50% of total billed charges,310.55,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,310.55,31.95,,5.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,369.36,38,,475.76,percent of total billed charges,38% of total billed charges,388.8,40,,20.448,percent of total billed charges,40% of total billed charges,3595.94,5247,
CATHETER UROMAX BALLOON DILATION U2Q/6-4/5.8-A,4200245,CDM,270,RC,,,OUTPATIENT,,,780,468,,663,85,,530.4,Percent of total billed charges,85% of total billed charges,390,50,,312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,390,50,,312,percent of total billed charges,50% of total billed charges,249.21,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,249.21,31.95,,5.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,296.4,38,,456,percent of total billed charges,38% of total billed charges,312,40,,20.448,percent of total billed charges,40% of total billed charges,3596.94,5248,
STENT URETERAL POLARIS ULTRA 5/22,4200246,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,122.69,31.95,,6.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,475.76,percent of total billed charges,38% of total billed charges,137.39,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,3597.94,5249,
STENT URETERAL POLARIS ULTRA 5/30,4200247,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,24.744,percent of total billed charges,35.15% of total billed charges,122.69,31.95,,8.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,370.88,percent of total billed charges,38% of total billed charges,137.39,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,3598.94,5250,
FIBERS LASER FLEXIVA 1000 HIGH POWER,4200248,CDM,270,RC,,,OUTPATIENT,,,2120,1272,,1802,85,,1441.6,Percent of total billed charges,85% of total billed charges,1060,50,,848,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1060,50,,848,percent of total billed charges,50% of total billed charges,677.34,31.95,,1285.088,percent of total billed charges,31.95% of total billed charges,677.34,31.95,,8.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,805.6,38,,328.624,percent of total billed charges,38% of total billed charges,848,40,,1168.096,percent of total billed charges,40% of total billed charges,3599.94,5251,
GUIDEWIRE .038 SENSOR DUAL-FLEX NITINOL,4200250,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,132,79.2,,138.6,105,,,case rate,pays based on 105% of threshold rate,66,50,,52.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,66,50,,52.8,percent of total billed charges,50% of total billed charges,46.4,35.15,,570.84,percent of total billed charges,35.15% of total billed charges,122.69,31.95,,9.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.16,38,,402.8,percent of total billed charges,38% of total billed charges,42.17,31.95,,518.872,percent of total billed charges,31.95% of total billed charges,3600.94,5252,
GUIDEWIRE SENSOR .038 DUAL FLEX ANG/150CM,4200251,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,372,223.2,,390.6,105,,,case rate,pays based on 105% of threshold rate,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,130.76,35.15,,449.92,percent of total billed charges,35.15% of total billed charges,123.33,31.95,,9.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,111.904,percent of total billed charges,38% of total billed charges,118.85,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,3601.94,5253,
NAVIGATOR HD URETERAL ACCESS SHEATH 11/13FR28,4200252,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,9.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,120.992,percent of total billed charges,38% of total billed charges,148.8,40,,421.744,percent of total billed charges,40% of total billed charges,3602.94,5254,
NAVIGATOR HD URETERAL ACCESS SHEATH 11/13FR36,4200253,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,27.544,percent of total billed charges,38% of total billed charges,148.8,40,,421.744,percent of total billed charges,40% of total billed charges,3603.94,5255,
NAVIGATOR HD URETERAL ACCESS SHEATH 11/13FR46,4200254,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,12.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,27.544,percent of total billed charges,38% of total billed charges,148.8,40,,421.744,percent of total billed charges,40% of total billed charges,3604.94,5256,
NAVIGATOR HD URETERAL ACCESS SHEATH 12/14FR28,4200255,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,12.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,27.544,percent of total billed charges,38% of total billed charges,148.8,40,,690.12,percent of total billed charges,40% of total billed charges,3605.94,5257,
NAVIGATOR HD URETERAL ACCESS SHEATH 12/14FR36,4200256,CDM,270,RC,,,OUTPATIENT,,,132,79.2,,112.2,85,,89.76,Percent of total billed charges,85% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,66,50,,52.8,percent of total billed charges,50% of total billed charges,42.17,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,42.17,31.95,,12.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.16,38,,27.544,percent of total billed charges,38% of total billed charges,52.8,40,,498.424,percent of total billed charges,40% of total billed charges,3606.94,5258,
NAVIGATOR HD URETERAL ACCESS SHEATH 12/14FR46,4200257,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,13.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,90.592,percent of total billed charges,38% of total billed charges,148.8,40,,498.424,percent of total billed charges,40% of total billed charges,3607.94,5259,
NAVIGATOR HD URETERAL ACCESS SHEATH 13/15FR28,4200258,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,1546.6,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,13.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,90.592,percent of total billed charges,38% of total billed charges,148.8,40,,1405.8,percent of total billed charges,40% of total billed charges,3608.94,5260,
FIBERS FLEXIVA 200 TRACTIP,4200260,CDM,270,RC,,,OUTPATIENT,,,1383,829.8,,1175.55,85,,940.44,Percent of total billed charges,85% of total billed charges,691.5,50,,553.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,691.5,50,,553.2,percent of total billed charges,50% of total billed charges,441.87,31.95,,570.84,percent of total billed charges,31.95% of total billed charges,441.87,31.95,,13.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,525.54,38,,27.544,percent of total billed charges,38% of total billed charges,553.2,40,,518.872,percent of total billed charges,40% of total billed charges,3609.94,5261,
SUTURE 0.0 CHROMIC GUT BP-1,4200262,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,449.92,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,14.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,91.2,percent of total billed charges,38% of total billed charges,12,40,,408.96,percent of total billed charges,40% of total billed charges,3610.94,5262,
BLADE RING CUTTER,4200269,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,210.904,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,14.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,27.544,percent of total billed charges,38% of total billed charges,10,40,,191.704,percent of total billed charges,40% of total billed charges,3611.94,5263,
STREP A DIPSTICK RAPID TEST,4200274,CDM,270,RC,,,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75,50,,60,percent of total billed charges,50% of total billed charges,47.93,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,27.544,percent of total billed charges,38% of total billed charges,60,40,,690.12,percent of total billed charges,40% of total billed charges,3612.94,5264,
BLAKE DRAIN 10FR ROUND HUBLESS,4200279,CDM,270,RC,,,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,60,50,,48,percent of total billed charges,50% of total billed charges,38.34,31.95,,56.24,percent of total billed charges,31.95% of total billed charges,38.34,31.95,,15.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.6,38,,27.544,percent of total billed charges,38% of total billed charges,48,40,,51.12,percent of total billed charges,40% of total billed charges,3613.94,5265,
BLAKE DRAIN 15FT ROUND HUBLESS,4200281,CDM,270,RC,,,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,60,50,,48,percent of total billed charges,50% of total billed charges,38.34,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,38.34,31.95,,17.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.6,38,,547.2,percent of total billed charges,38% of total billed charges,48,40,,498.424,percent of total billed charges,40% of total billed charges,3614.94,5266,
BANDAID 3/4''''X 3'''' CHILD,4200283,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,18.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,27.544,percent of total billed charges,38% of total billed charges,7.2,40,,421.744,percent of total billed charges,40% of total billed charges,3615.94,5267,
THERMOMETER ORAL DIGITAL,4200285,CDM,270,RC,,,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,18.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.3,38,,27.544,percent of total billed charges,38% of total billed charges,34,40,,920.16,percent of total billed charges,40% of total billed charges,3616.94,5268,
PCI KIT/4,4200301,CDM,270,RC,,,OUTPATIENT,,,134.08,80.448,,113.97,85,,91.176,Percent of total billed charges,85% of total billed charges,67.04,50,,53.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67.04,50,,53.632,percent of total billed charges,50% of total billed charges,42.84,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,42.84,31.95,,18.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.95,38,,27.544,percent of total billed charges,38% of total billed charges,53.63,40,,498.424,percent of total billed charges,40% of total billed charges,3617.94,5269,
BACTI-STAT AE HAND SOAP 1000ML,4200302,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,136.744,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,136.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,27.544,percent of total billed charges,38% of total billed charges,7.2,40,,171.2,percent of total billed charges,40% of total billed charges,3618.94,5270,
SYRINGE 5CC LL,4200307,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,19.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,27.544,percent of total billed charges,38% of total billed charges,11.2,40,,460.08,percent of total billed charges,40% of total billed charges,3619.94,5271,
BOUFFANT CAPS BLUE  LG 24'''',4200311,CDM,270,RC,,,OUTPATIENT,,,135,81,,114.75,85,,91.8,Percent of total billed charges,85% of total billed charges,67.5,50,,54,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67.5,50,,54,percent of total billed charges,50% of total billed charges,43.13,31.95,,760.648,percent of total billed charges,31.95% of total billed charges,43.13,31.95,,22.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,51.3,38,,30.4,percent of total billed charges,38% of total billed charges,54,40,,691.4,percent of total billed charges,40% of total billed charges,3620.94,5272,
COLOSTOMY DRAIN BAG 1.75'''',4200319,CDM,270,RC,A5063,HCPCS,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,2.11,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,123.33,31.95,,22.888,percent of total billed charges,31.95% of total billed charges,3.69,100,,,fee schedule,100% of CMS custom fee schedule,2.28,38,,209.76,percent of total billed charges,38% of total billed charges,1.92,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,3621.94,5273,
STENT URETERAL POLARIS ULTRA 5/24,4200320,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,21.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,43.136,percent of total billed charges,38% of total billed charges,137.39,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,3622.94,5274,
STENT URETERAL POLARIS ULTRA 5/26,4200321,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,760.648,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,23.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,224.96,percent of total billed charges,38% of total billed charges,137.39,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,3623.94,5275,
STENT URETERAL POLARIS ULTRA 5/28,4200322,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,430,258,,451.5,105,,,case rate,pays based on 105% of threshold rate,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,151.15,35.15,,760.648,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,170.24,percent of total billed charges,38% of total billed charges,137.39,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,3624.94,5276,
STAPLER RELOAD 60MM,4200325,CDM,270,RC,,,OUTPATIENT,,,115.2,69.12,,97.92,85,,78.336,Percent of total billed charges,85% of total billed charges,57.6,50,,46.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57.6,50,,46.08,percent of total billed charges,50% of total billed charges,36.81,31.95,,210.904,percent of total billed charges,31.95% of total billed charges,36.81,31.95,,58.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.78,38,,170.24,percent of total billed charges,38% of total billed charges,46.08,40,,191.704,percent of total billed charges,40% of total billed charges,3625.94,5277,
INTROCAN NEEDLE 18GX1.88,4200327,CDM,270,RC,,,OUTPATIENT,,,7.9,4.74,,6.72,85,,5.376,Percent of total billed charges,85% of total billed charges,3.95,50,,3.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.95,50,,3.16,percent of total billed charges,50% of total billed charges,2.52,31.95,,379.624,percent of total billed charges,31.95% of total billed charges,2.52,31.95,,60.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3,38,,170.24,percent of total billed charges,38% of total billed charges,3.16,40,,345.064,percent of total billed charges,40% of total billed charges,3626.94,5278,
NAVIGATOR HD URETERAL ACCESS SHEATH 13/15FR36,4200331,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,210.904,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,69.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,227.088,percent of total billed charges,38% of total billed charges,148.8,40,,191.704,percent of total billed charges,40% of total billed charges,3627.94,5279,
NAVIGATOR HD URETERAL ACCESS SHEATH 13/15FR46,4200332,CDM,270,RC,,,OUTPATIENT,,,372,223.2,,316.2,85,,252.96,Percent of total billed charges,85% of total billed charges,186,50,,148.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,186,50,,148.8,percent of total billed charges,50% of total billed charges,118.85,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,118.85,31.95,,134.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.36,38,,62.288,percent of total billed charges,38% of total billed charges,148.8,40,,690.12,percent of total billed charges,40% of total billed charges,3628.94,5280,
CATHETER UROMAX BALLOON DILATION U2Q/6-4/5.8-B,4200333,CDM,270,RC,,,OUTPATIENT,,,780,468,,663,85,,530.4,Percent of total billed charges,85% of total billed charges,390,50,,312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,390,50,,312,percent of total billed charges,50% of total billed charges,249.21,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,249.21,31.95,,139.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,296.4,38,,62.288,percent of total billed charges,38% of total billed charges,312,40,,498.424,percent of total billed charges,40% of total billed charges,3629.94,5281,
BOOK MONEY RECEIPT 3PART,4200334,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,228,percent of total billed charges,38% of total billed charges,5.4,40,,236.8,percent of total billed charges,40% of total billed charges,3630.94,5282,
SUTURE PDS II,4200335,CDM,270,RC,,,OUTPATIENT,,,22.77,13.662,,19.35,85,,15.48,Percent of total billed charges,85% of total billed charges,11.39,50,,9.112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.39,50,,9.112,percent of total billed charges,50% of total billed charges,7.28,31.95,,572.544,percent of total billed charges,31.95% of total billed charges,7.28,31.95,,572.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.65,38,,86.184,percent of total billed charges,38% of total billed charges,9.11,40,,716.8,percent of total billed charges,40% of total billed charges,3631.94,5283,
"RING CUSHION, DAY US 16''''",4200339,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,32.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,86.184,percent of total billed charges,38% of total billed charges,13.2,40,,498.424,percent of total billed charges,40% of total billed charges,3632.94,5284,
SYRINGE TB 1CC 27GX1/2'''' DETACHABLE NEEDLE,4200346,CDM,270,RC,,,OUTPATIENT,,,4.5,2.7,,3.83,85,,3.064,Percent of total billed charges,85% of total billed charges,2.25,50,,1.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.25,50,,1.8,percent of total billed charges,50% of total billed charges,1.44,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,1.44,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.71,38,,182.4,percent of total billed charges,38% of total billed charges,1.8,40,,128,percent of total billed charges,40% of total billed charges,3633.94,5285,
PERIPHERAL CATH TWIN 20/22ML,4200365,CDM,270,RC,,,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,10.86,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,10.86,31.95,,27.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,165.984,percent of total billed charges,38% of total billed charges,13.6,40,,460.08,percent of total billed charges,40% of total billed charges,3634.94,5286,
NASOPHARYNGEAL AIRWAY 24FR,4200371,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,27.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,260.528,percent of total billed charges,38% of total billed charges,6,40,,690.12,percent of total billed charges,40% of total billed charges,3635.94,5287,
SPORTS ANKLE BRACE MR,4200373,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,210.904,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,331.36,percent of total billed charges,38% of total billed charges,18,40,,191.704,percent of total billed charges,40% of total billed charges,3636.94,5288,
CLAVICAL STRAP YOUTH,4200374,CDM,270,RC,,,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,29.71,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,29.71,31.95,,31.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.34,38,,355.376,percent of total billed charges,38% of total billed charges,37.2,40,,920.16,percent of total billed charges,40% of total billed charges,3637.94,5289,
CLAVICLE SPLINT PADDED SM,4200375,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,31.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,273.6,percent of total billed charges,38% of total billed charges,10.8,40,,498.424,percent of total billed charges,40% of total billed charges,3638.94,5290,
TONER TN350 (BROTHER),4200376,CDM,270,RC,,,OUTPATIENT,,,123,73.8,,104.55,85,,83.64,Percent of total billed charges,85% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,39.3,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,39.3,31.95,,4.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.74,38,,355.68,percent of total billed charges,38% of total billed charges,49.2,40,,1035.184,percent of total billed charges,40% of total billed charges,3639.94,5291,
CATHETER 12FR ALL PURPOSE RED,4200380,CDM,270,RC,,,OUTPATIENT,,,1.6,0.96,,1.36,85,,1.088,Percent of total billed charges,85% of total billed charges,0.8,50,,0.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.8,50,,0.64,percent of total billed charges,50% of total billed charges,0.51,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,0.51,31.95,,5.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.61,38,,242.288,percent of total billed charges,38% of total billed charges,0.64,40,,498.424,percent of total billed charges,40% of total billed charges,3640.94,5292,
CLIP ROTATE SHAFT APPLIER MULTI,4200381,CDM,270,RC,,,OUTPATIENT,,,222.82,133.692,,189.4,85,,151.52,Percent of total billed charges,85% of total billed charges,111.41,50,,89.128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,111.41,50,,89.128,percent of total billed charges,50% of total billed charges,71.19,31.95,,504.752,percent of total billed charges,31.95% of total billed charges,71.19,31.95,,5.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,84.67,38,,242.288,percent of total billed charges,38% of total billed charges,89.13,40,,458.8,percent of total billed charges,40% of total billed charges,3641.94,5293,
STRYKERFLOW 2,4200390,CDM,270,RC,,,OUTPATIENT,,,144.2,86.52,,122.57,85,,98.056,Percent of total billed charges,85% of total billed charges,72.1,50,,57.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,72.1,50,,57.68,percent of total billed charges,50% of total billed charges,46.07,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,46.07,31.95,,5.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.8,38,,35.04,percent of total billed charges,38% of total billed charges,57.68,40,,20.448,percent of total billed charges,40% of total billed charges,3642.94,5294,
MOUSE PAD,4200401,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,242.288,percent of total billed charges,38% of total billed charges,6.4,40,,14.4,percent of total billed charges,40% of total billed charges,3643.94,5295,
CREDIT CARD THERMAL RECEIPT 2.25'''',4200402,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,122.888,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,21.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,242.288,percent of total billed charges,38% of total billed charges,4.8,40,,111.696,percent of total billed charges,40% of total billed charges,3644.94,5296,
SALEM SUMP ANTI-REFLUX VALVE,4200406,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,7.38,35.15,,99.176,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,99.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,242.288,percent of total billed charges,38% of total billed charges,6.71,31.95,,124.16,percent of total billed charges,31.95% of total billed charges,3645.94,5297,
GLOVE EXAM MEDIUM NITRAL,4200411,CDM,270,RC,,,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,10.4,percent of total billed charges,50% of total billed charges,8.31,31.95,,232.6,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,232.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,82.552,percent of total billed charges,38% of total billed charges,10.4,40,,291.2,percent of total billed charges,40% of total billed charges,3646.94,5298,
ALCOHOL ISOPROPYL 16OZ,4200415,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1130.424,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,21.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,82.552,percent of total billed charges,38% of total billed charges,2,40,,1027.512,percent of total billed charges,40% of total billed charges,3647.94,5299,
BIOPSY CORE INSTRUMENT (MONOPTY) 11MM,4200416,CDM,270,RC,,,OUTPATIENT,,,147,88.2,,124.95,85,,99.96,Percent of total billed charges,85% of total billed charges,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,46.97,31.95,,50.616,percent of total billed charges,31.95% of total billed charges,46.97,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.86,38,,355.376,percent of total billed charges,38% of total billed charges,58.8,40,,46.008,percent of total billed charges,40% of total billed charges,3648.94,5300,
XEROFORM DRESSING 4X4,4200420,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,39.368,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,101.064,percent of total billed charges,38% of total billed charges,2,40,,35.784,percent of total billed charges,40% of total billed charges,3649.94,5301,
CERVICAL COLLAR PHIL LG,4200447,CDM,270,RC,L0140,HCPCS,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,14.76,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,71.86,100,,,fee schedule,100% of CMS custom fee schedule,15.96,38,,101.064,percent of total billed charges,38% of total billed charges,13.42,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,3650.94,5302,
CARDBOARD MOUTHPIECE FOR PLUM. FUNCTION,4200451,CDM,270,RC,,,OUTPATIENT,,,2.95,1.77,,2.51,85,,2.008,Percent of total billed charges,85% of total billed charges,1.48,50,,1.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.48,50,,1.184,percent of total billed charges,50% of total billed charges,0.94,31.95,,81.552,percent of total billed charges,31.95% of total billed charges,0.94,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.12,38,,101.064,percent of total billed charges,38% of total billed charges,1.18,40,,74.128,percent of total billed charges,40% of total billed charges,3651.94,5303,
BLOOD Y SET FOR HORIZON PUMP,4200460,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.57,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,86.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,51.936,percent of total billed charges,38% of total billed charges,4.15,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,3652.94,5304,
FLEXISENSOR BANDAGE PEDIATRIC,4200467,CDM,270,RC,,,OUTPATIENT,,,223,133.8,,189.55,85,,151.64,Percent of total billed charges,85% of total billed charges,111.5,50,,89.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,111.5,50,,89.2,percent of total billed charges,50% of total billed charges,71.25,31.95,,111.64,percent of total billed charges,31.95% of total billed charges,71.25,31.95,,90.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,84.74,38,,248.368,percent of total billed charges,38% of total billed charges,89.2,40,,101.472,percent of total billed charges,40% of total billed charges,3653.94,5305,
SP MONO RAPID TEST,4200470,CDM,270,RC,,,OUTPATIENT,,,159,95.4,,135.15,85,,108.12,Percent of total billed charges,85% of total billed charges,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,50.8,31.95,,61.864,percent of total billed charges,31.95% of total billed charges,50.8,31.95,,418.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.42,38,,12.68,percent of total billed charges,38% of total billed charges,63.6,40,,56.232,percent of total billed charges,40% of total billed charges,3654.94,5306,
ARMBOARD NEONATE,4200473,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,506.72,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,488.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,1.536,percent of total billed charges,38% of total billed charges,0.4,40,,460.592,percent of total billed charges,40% of total billed charges,3655.94,5307,
ARMBOARD LARGE,4200474,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,506.72,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,28.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,51.552,percent of total billed charges,38% of total billed charges,1.2,40,,460.592,percent of total billed charges,40% of total billed charges,3656.94,5308,
MASK FILTER SAFETY REGULAR,4200475,CDM,270,RC,,,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,16.93,31.95,,506.72,percent of total billed charges,31.95% of total billed charges,16.93,31.95,,31.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.14,38,,51.552,percent of total billed charges,38% of total billed charges,21.2,40,,460.592,percent of total billed charges,40% of total billed charges,3657.94,5309,
3% HYPERTONIC SC 500CC L8051,4200479,CDM,270,RC,,,OUTPATIENT,,,25.9,15.54,,22.02,85,,17.616,Percent of total billed charges,85% of total billed charges,12.95,50,,10.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.95,50,,10.36,percent of total billed charges,50% of total billed charges,8.28,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.28,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.84,38,,51.552,percent of total billed charges,38% of total billed charges,10.36,40,,8.32,percent of total billed charges,40% of total billed charges,3658.94,5310,
SUTURE 0.0 PROLENE MO-6 HGS-22,4200481,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,42.184,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,28.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,51.552,percent of total billed charges,38% of total billed charges,8.8,40,,38.344,percent of total billed charges,40% of total billed charges,3659.94,5311,
LOTION BODY  4 OZ,4200484,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,43.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,60.24,percent of total billed charges,38% of total billed charges,1.2,40,,460.08,percent of total billed charges,40% of total billed charges,3660.94,5312,
LEAD PASSPORT 2 3 LEAD SNAP SET,4200488,CDM,270,RC,,,OUTPATIENT,,,144,86.4,,122.4,85,,97.92,Percent of total billed charges,85% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,72,50,,57.6,percent of total billed charges,50% of total billed charges,46.01,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,46.01,31.95,,59.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.72,38,,60.24,percent of total billed charges,38% of total billed charges,57.6,40,,920.16,percent of total billed charges,40% of total billed charges,3661.94,5313,
LABEL DOCTOR NEON PINK STRIP,4200490,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,60.24,percent of total billed charges,38% of total billed charges,8.4,40,,67.2,percent of total billed charges,40% of total billed charges,3662.94,5314,
SYRINGE 60CC 2OZ CATH TIP,4200491,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.7,35.15,,68.616,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,8.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,60.24,percent of total billed charges,38% of total billed charges,0.64,31.95,,62.368,percent of total billed charges,31.95% of total billed charges,3663.94,5315,
SYRINGE TB,4200492,CDM,270,RC,,,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,47.5,50,,38,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47.5,50,,38,percent of total billed charges,50% of total billed charges,30.35,31.95,,868.912,percent of total billed charges,31.95% of total billed charges,30.35,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.1,38,,507.68,percent of total billed charges,38% of total billed charges,38,40,,789.808,percent of total billed charges,40% of total billed charges,3664.94,5316,
TAPE SILK 3'''',4200493,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,89.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,59.072,percent of total billed charges,38% of total billed charges,16,40,,74.632,percent of total billed charges,40% of total billed charges,3665.94,5317,
DRESSING TUBIGRIP SIZE G,4200496,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,89.984,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,507.68,percent of total billed charges,38% of total billed charges,1.6,40,,81.792,percent of total billed charges,40% of total billed charges,3666.94,5318,
WORD BARTHOLIN CATHETER 10F LATEX,4200497,CDM,270,RC,,,OUTPATIENT,,,66.4,39.84,,56.44,85,,45.152,Percent of total billed charges,85% of total billed charges,33.2,50,,26.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.2,50,,26.56,percent of total billed charges,50% of total billed charges,21.21,31.95,,89.984,percent of total billed charges,31.95% of total billed charges,21.21,31.95,,51.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.23,38,,59.072,percent of total billed charges,38% of total billed charges,26.56,40,,81.792,percent of total billed charges,40% of total billed charges,3667.94,5319,
BORDER MEPILEX ADHESIVE 3X3,4200498,CDM,270,RC,,,OUTPATIENT,,,12.6,7.56,,10.71,85,,8.568,Percent of total billed charges,85% of total billed charges,6.3,50,,5.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.3,50,,5.04,percent of total billed charges,50% of total billed charges,4.03,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,4.03,31.95,,6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.79,38,,501.6,percent of total billed charges,38% of total billed charges,5.04,40,,76.68,percent of total billed charges,40% of total billed charges,3668.94,5320,
CRICOTHYROTOMY TRAY,4200503,CDM,270,RC,,,OUTPATIENT,,,1436,861.6,,1220.6,85,,976.48,Percent of total billed charges,85% of total billed charges,718,50,,574.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,718,50,,574.4,percent of total billed charges,50% of total billed charges,458.8,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,458.8,31.95,,6.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,545.68,38,,59.072,percent of total billed charges,38% of total billed charges,574.4,40,,498.424,percent of total billed charges,40% of total billed charges,3669.94,5321,
COBAN STRETCH 2'''' LATEX,4200504,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,56.24,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,6.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,50.496,percent of total billed charges,38% of total billed charges,2.4,40,,51.12,percent of total billed charges,40% of total billed charges,3670.94,5322,
COBAN STRETCH 1'''' LATEX,4200505,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1560.664,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,64.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,59.072,percent of total billed charges,38% of total billed charges,2,40,,1418.584,percent of total billed charges,40% of total billed charges,3671.94,5323,
COBAN STRETCH 4'''' LF,4200506,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,82.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,36.344,percent of total billed charges,38% of total billed charges,5.2,40,,555.928,percent of total billed charges,40% of total billed charges,3672.94,5324,
PROBE WELL KIT TEMPERATURE ORAL,4200507,CDM,270,RC,,,OUTPATIENT,,,137,82.2,,116.45,85,,93.16,Percent of total billed charges,85% of total billed charges,68.5,50,,54.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,68.5,50,,54.8,percent of total billed charges,50% of total billed charges,43.77,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,43.77,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,52.06,38,,36.344,percent of total billed charges,38% of total billed charges,54.8,40,,112,percent of total billed charges,40% of total billed charges,3673.94,5325,
LEVINE TUBE 12,4200514,CDM,270,RC,,,OUTPATIENT,,,10.55,6.33,,8.97,85,,7.176,Percent of total billed charges,85% of total billed charges,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,3.37,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,3.37,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.01,38,,378.48,percent of total billed charges,38% of total billed charges,4.22,40,,112,percent of total billed charges,40% of total billed charges,3674.94,5326,
PETROLEUM GAUZE 3X18,4200516,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,95.048,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,9.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,36.344,percent of total billed charges,38% of total billed charges,1.6,40,,86.392,percent of total billed charges,40% of total billed charges,3675.94,5327,
GEL SHAVING 1.5OZ,4200517,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,654.912,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,23.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,36.344,percent of total billed charges,38% of total billed charges,0.8,40,,595.296,percent of total billed charges,40% of total billed charges,3676.94,5328,
FLEXISENSOR BANDAGES ADULT,4200518,CDM,270,RC,,,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,56,50,,44.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56,50,,44.8,percent of total billed charges,50% of total billed charges,35.78,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,35.78,31.95,,2200.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.56,38,,36.344,percent of total billed charges,38% of total billed charges,44.8,40,,76.68,percent of total billed charges,40% of total billed charges,3677.94,5329,
SYRINGE 3CC 18GX1 305060,4200519,CDM,270,RC,,,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,13.42,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,8772.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,543.552,percent of total billed charges,38% of total billed charges,16.8,40,,76.68,percent of total billed charges,40% of total billed charges,3678.94,5330,
CIDEX OPA GAL,4200522,CDM,270,RC,,,OUTPATIENT,,,89,53.4,,75.65,85,,60.52,Percent of total billed charges,85% of total billed charges,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,28.44,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,28.44,31.95,,167.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.82,38,,543.552,percent of total billed charges,38% of total billed charges,35.6,40,,76.68,percent of total billed charges,40% of total billed charges,3679.94,5331,
EKG GRAPH PAPER 3RLS/BX ER/IC DEFIBULATOR,4200528,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,434.112,percent of total billed charges,38% of total billed charges,4,40,,76.68,percent of total billed charges,40% of total billed charges,3680.94,5332,
BOVIE TIP 2MM NEEDLE MEGADYNE,4200529,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,543.552,percent of total billed charges,38% of total billed charges,18,40,,460.08,percent of total billed charges,40% of total billed charges,3681.94,5333,
BOVIE SUCTION SMOKE EVACUATOR,4200534,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,11.95,35.15,,113.04,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,625.936,percent of total billed charges,38% of total billed charges,10.86,31.95,,102.752,percent of total billed charges,31.95% of total billed charges,3682.94,5334,
BOTTLE EVACUATED 1000ML    (1A8506 2000ML),4200536,CDM,270,RC,,,OUTPATIENT,,,30.87,18.522,,26.24,85,,20.992,Percent of total billed charges,85% of total billed charges,15.44,50,,12.352,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.44,50,,12.352,percent of total billed charges,50% of total billed charges,9.86,31.95,,42.184,percent of total billed charges,31.95% of total billed charges,9.86,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.73,38,,543.552,percent of total billed charges,38% of total billed charges,12.35,40,,38.344,percent of total billed charges,40% of total billed charges,3683.94,5335,
WATER NURSERY WATER 1 GAL,4200537,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,42.184,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,543.552,percent of total billed charges,38% of total billed charges,2.4,40,,38.344,percent of total billed charges,40% of total billed charges,3684.94,5336,
SUCTION SWAB SYSTEM,4200540,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1560.664,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,661.2,percent of total billed charges,38% of total billed charges,2,40,,1418.584,percent of total billed charges,40% of total billed charges,3685.94,5337,
TOOTHPASTE 0.6 OZ,4200542,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,54.256,percent of total billed charges,38% of total billed charges,0.4,40,,555.928,percent of total billed charges,40% of total billed charges,3686.94,5338,
MICRO DRIP SET,4200544,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,54.256,percent of total billed charges,38% of total billed charges,11.6,40,,108.8,percent of total billed charges,40% of total billed charges,3687.94,5339,
HUBER NEEDLE W/TUBING 20GX1,4200545,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,361.344,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,25.84,percent of total billed charges,38% of total billed charges,12.8,40,,328.448,percent of total billed charges,40% of total billed charges,3688.94,5340,
HUBER NEEDLE W/TUBING 20GX1.5'''',4200546,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,97.016,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,143.488,percent of total billed charges,38% of total billed charges,17.6,40,,88.184,percent of total billed charges,40% of total billed charges,3689.94,5341,
BATTERY 3V (GLUCOMETER CONTOUR),4200550,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,97.016,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,91.2,percent of total billed charges,38% of total billed charges,1.6,40,,88.184,percent of total billed charges,40% of total billed charges,3690.94,5342,
NASOPHARYNGEAL AIRWAY 26FR,4200551,CDM,270,RC,,,OUTPATIENT,,,14.3,8.58,,12.16,85,,9.728,Percent of total billed charges,85% of total billed charges,7.15,50,,5.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.15,50,,5.72,percent of total billed charges,50% of total billed charges,4.57,31.95,,97.016,percent of total billed charges,31.95% of total billed charges,4.57,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.43,38,,151.392,percent of total billed charges,38% of total billed charges,5.72,40,,88.184,percent of total billed charges,40% of total billed charges,3691.94,5343,
NASOPHARYNGEAL AIRWAY 28FR,4200552,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,97.016,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,148.96,percent of total billed charges,38% of total billed charges,4.8,40,,88.184,percent of total billed charges,40% of total billed charges,3692.94,5344,
NASOPHARYNGEAL AIRWAY 30FR,4200553,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,12.768,percent of total billed charges,38% of total billed charges,4.8,40,,48,percent of total billed charges,40% of total billed charges,3693.94,5345,
NASOPHARYNGEAL AIRWAY 32FR,4200554,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,12.768,percent of total billed charges,38% of total billed charges,4.8,40,,48,percent of total billed charges,40% of total billed charges,3694.94,5346,
NASOPHARYNGEAL AIRWAY 34FR,4200555,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,133.568,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,70.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,12.768,percent of total billed charges,38% of total billed charges,6,40,,121.408,percent of total billed charges,40% of total billed charges,3695.94,5347,
NASOPHARYNGEAL AIRWAY 36FR,4200556,CDM,270,RC,,,OUTPATIENT,,,14.95,8.97,,12.71,85,,10.168,Percent of total billed charges,85% of total billed charges,7.48,50,,5.984,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.48,50,,5.984,percent of total billed charges,50% of total billed charges,4.78,31.95,,126.544,percent of total billed charges,31.95% of total billed charges,4.78,31.95,,70.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.68,38,,259.92,percent of total billed charges,38% of total billed charges,5.98,40,,115.024,percent of total billed charges,40% of total billed charges,3696.94,5348,
ET TUBE   2.0 UNCUFFED,4200557,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,421.8,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,146.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,258.4,percent of total billed charges,38% of total billed charges,5.4,40,,383.4,percent of total billed charges,40% of total billed charges,3697.94,5349,
ET TUBE   2.5 UNCUFFED,4200558,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,97.016,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,23.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,304,percent of total billed charges,38% of total billed charges,5.4,40,,88.184,percent of total billed charges,40% of total billed charges,3698.94,5350,
ET TUBE   3.0 UNCUFFED   MAGILL TIP,4200559,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,379.624,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,3484.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,304,percent of total billed charges,38% of total billed charges,5.4,40,,345.064,percent of total billed charges,40% of total billed charges,3699.94,5351,
ET TUBE 3.5 UNCUFFED MAGILL TIP,4200560,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,233.872,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,233.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,424.08,percent of total billed charges,38% of total billed charges,5.4,40,,292.8,percent of total billed charges,40% of total billed charges,3700.94,5352,
ET TUBE  4.0 CUFFED,4200561,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,120.136,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,120.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,346.256,percent of total billed charges,38% of total billed charges,5.4,40,,150.4,percent of total billed charges,40% of total billed charges,3701.94,5353,
ET TUBE  4.5 CUFFED,4200562,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,274.168,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,3.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,261.44,percent of total billed charges,38% of total billed charges,3.6,40,,249.208,percent of total billed charges,40% of total billed charges,3702.94,5354,
ET TUBE   5.5 CUFFED,4200563,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,95.608,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,17.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,35.64,percent of total billed charges,38% of total billed charges,3.6,40,,86.904,percent of total billed charges,40% of total billed charges,3703.94,5355,
ET TUBE   6.0 CUFFED,4200564,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,15.464,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,28.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,35.64,percent of total billed charges,38% of total billed charges,3.6,40,,14.056,percent of total billed charges,40% of total billed charges,3704.94,5356,
ET TUBE   6.5 CUFFED,4200565,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,6.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,35.64,percent of total billed charges,38% of total billed charges,4,40,,1035.184,percent of total billed charges,40% of total billed charges,3705.94,5357,
ET TUBE   8.5 CUFFED,4200569,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,6.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,169.408,percent of total billed charges,38% of total billed charges,5.4,40,,498.424,percent of total billed charges,40% of total billed charges,3706.94,5358,
ET TUBE   9.0 CUFFED,4200570,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,6.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,169.408,percent of total billed charges,38% of total billed charges,3.6,40,,230.04,percent of total billed charges,40% of total billed charges,3707.94,5359,
MIC-KEY 18FR FEEDING TUBE,4200573,CDM,270,RC,,,OUTPATIENT,,,202,121.2,,171.7,85,,137.36,Percent of total billed charges,85% of total billed charges,101,50,,80.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,101,50,,80.8,percent of total billed charges,50% of total billed charges,64.54,31.95,,717.064,percent of total billed charges,31.95% of total billed charges,64.54,31.95,,7.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76.76,38,,1767.76,percent of total billed charges,38% of total billed charges,80.8,40,,651.784,percent of total billed charges,40% of total billed charges,3708.94,5360,
INTUBATING STYLET 6FR,4200575,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,1138.864,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,9.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,1092.88,percent of total billed charges,38% of total billed charges,5.2,40,,1035.184,percent of total billed charges,40% of total billed charges,3709.94,5361,
CAUTERY SURGICAL HI TEMP LOOP,4200578,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,15.82,35.15,,270.936,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,270.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,1092.88,percent of total billed charges,38% of total billed charges,14.38,31.95,,339.2,percent of total billed charges,31.95% of total billed charges,3710.94,5362,
RAZOR TWIN BLADE,4200579,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,169.408,percent of total billed charges,38% of total billed charges,0.8,40,,498.424,percent of total billed charges,40% of total billed charges,3711.94,5363,
"FMC RAZOR, TWIN BLADE",4200579,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,129.352,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,3.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,1099.568,percent of total billed charges,38% of total billed charges,0.8,40,,117.576,percent of total billed charges,40% of total billed charges,3712.94,5364,
EAR SPECULUM WELCHALLEN 4.25MM,4200582,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,129.352,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,10.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,1094.4,percent of total billed charges,38% of total billed charges,2,40,,117.576,percent of total billed charges,40% of total billed charges,3713.94,5365,
EAR SPECULUM WELCHALLEN 2.75MM,4200583,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,39.368,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,8.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,169.408,percent of total billed charges,38% of total billed charges,2,40,,35.784,percent of total billed charges,40% of total billed charges,3714.94,5366,
TAPE TRANSPORE 1'''',4200585,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,9.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,1094.4,percent of total billed charges,38% of total billed charges,12.8,40,,74.632,percent of total billed charges,40% of total billed charges,3715.94,5367,
TAPE TRANSPORE 2'''',4200586,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,9.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,169.408,percent of total billed charges,38% of total billed charges,11.6,40,,74.632,percent of total billed charges,40% of total billed charges,3716.94,5368,
TAPE TRANSPORE 3'''',4200587,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,9.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,11.816,percent of total billed charges,38% of total billed charges,11.6,40,,74.632,percent of total billed charges,40% of total billed charges,3717.94,5369,
LANCETS QUIKHEEL INFANT,4200591,CDM,270,RC,,,OUTPATIENT,,,106,63.6,,90.1,85,,72.08,Percent of total billed charges,85% of total billed charges,53,50,,42.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53,50,,42.4,percent of total billed charges,50% of total billed charges,33.87,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,33.87,31.95,,10.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.28,38,,118.256,percent of total billed charges,38% of total billed charges,42.4,40,,74.632,percent of total billed charges,40% of total billed charges,3718.94,5370,
AUTOGUARD INSYTE 18GX1.88,4200592,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,3.16,35.15,,506.72,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,3.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,118.256,percent of total billed charges,38% of total billed charges,2.88,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,3719.94,5371,
FMC AUTOGUARD INSYTE 18 G,4200592,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,506.72,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,11.816,percent of total billed charges,38% of total billed charges,3.6,40,,460.592,percent of total billed charges,40% of total billed charges,3720.94,5372,
AUTOGUARD INSYTE 24G,4200595,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,3.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,142.88,percent of total billed charges,38% of total billed charges,3.6,40,,421.744,percent of total billed charges,40% of total billed charges,3721.94,5373,
FMC AUTOGUARD INSYTE 24G,4200595,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,263.016,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,263.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,118.256,percent of total billed charges,38% of total billed charges,3.6,40,,329.28,percent of total billed charges,40% of total billed charges,3722.94,5374,
5-IN-1 CONNECTOR,4200596,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,2856.432,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,3.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,144.4,percent of total billed charges,38% of total billed charges,0.4,40,,2596.384,percent of total billed charges,40% of total billed charges,3723.94,5375,
SCALPEL #10 DISPOSABLE,4200597,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,379.624,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,6.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,140.752,percent of total billed charges,38% of total billed charges,1.2,40,,345.064,percent of total billed charges,40% of total billed charges,3724.94,5376,
SCALPEL #12 DISPOSABLE,4200599,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,7.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,121.6,percent of total billed charges,38% of total billed charges,2,40,,498.424,percent of total billed charges,40% of total billed charges,3725.94,5377,
MEDICINE CUP PLASTIC,4200603,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,118.256,percent of total billed charges,38% of total billed charges,1.6,40,,131.52,percent of total billed charges,40% of total billed charges,3726.94,5378,
TUBE GASTRIC 8FR,4200606,CDM,270,RC,,,OUTPATIENT,,,54,32.4,,45.9,85,,36.72,Percent of total billed charges,85% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27,50,,21.6,percent of total billed charges,50% of total billed charges,17.25,31.95,,72.552,percent of total billed charges,31.95% of total billed charges,17.25,31.95,,35.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.52,38,,144.4,percent of total billed charges,38% of total billed charges,21.6,40,,65.944,percent of total billed charges,40% of total billed charges,3727.94,5379,
TUBE GASTRIC 16FR,4200607,CDM,270,RC,B4087,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,19.68,35.15,,790.176,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,42.632,percent of total billed charges,31.95% of total billed charges,40.27,100,,,fee schedule,100% of CMS custom fee schedule,21.28,38,,11.816,percent of total billed charges,38% of total billed charges,17.89,31.95,,718.24,percent of total billed charges,31.95% of total billed charges,3728.94,5380,
TUBE GASTRIC 18FR,4200608,CDM,270,RC,B4087,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,19.68,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,48.808,percent of total billed charges,31.95% of total billed charges,40.27,100,,,fee schedule,100% of CMS custom fee schedule,21.28,38,,11.816,percent of total billed charges,38% of total billed charges,17.89,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,3729.94,5381,
TUBE GASTRIC 20FR,4200609,CDM,270,RC,B4087,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,19.68,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,40.27,100,,,fee schedule,100% of CMS custom fee schedule,21.28,38,,11.816,percent of total billed charges,38% of total billed charges,17.89,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,3730.94,5382,
TUBE GASTRIC 22FR,4200610,CDM,270,RC,B4087,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,19.68,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,124.29,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,40.27,100,,,fee schedule,100% of CMS custom fee schedule,21.28,38,,144.4,percent of total billed charges,38% of total billed charges,17.89,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,3731.94,5383,
TUBE GASTRIC 24FR,4200611,CDM,270,RC,B4087,HCPCS,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,19.68,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,12.46,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,40.27,100,,,fee schedule,100% of CMS custom fee schedule,21.28,38,,11.816,percent of total billed charges,38% of total billed charges,17.89,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,3732.94,5384,
SALEM SUMP TUBE 12,4200612,CDM,270,RC,,,OUTPATIENT,,,10.75,6.45,,9.14,85,,7.312,Percent of total billed charges,85% of total billed charges,5.38,50,,4.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.38,50,,4.304,percent of total billed charges,50% of total billed charges,3.43,31.95,,506.72,percent of total billed charges,31.95% of total billed charges,3.43,31.95,,3.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.09,38,,11.816,percent of total billed charges,38% of total billed charges,4.3,40,,460.592,percent of total billed charges,40% of total billed charges,3733.94,5385,
SALEM SUMP TUBE 14,4200613,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,4.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,8.456,percent of total billed charges,38% of total billed charges,2.8,40,,920.16,percent of total billed charges,40% of total billed charges,3734.94,5386,
SALEM SUMP TUBE 16,4200614,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.46,35.15,,422.928,percent of total billed charges,35.15% of total billed charges,125.24,31.95,,7.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,12.368,percent of total billed charges,38% of total billed charges,2.24,31.95,,384.424,percent of total billed charges,31.95% of total billed charges,3735.94,5387,
SALEM SUMP TUBE 18,4200615,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,685.824,percent of total billed charges,38% of total billed charges,2.8,40,,76.68,percent of total billed charges,40% of total billed charges,3736.94,5388,
LEVINE TUBE 14,4200616,CDM,270,RC,,,OUTPATIENT,,,10.55,6.33,,8.97,85,,7.176,Percent of total billed charges,85% of total billed charges,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,3.37,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,3.37,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.01,38,,685.52,percent of total billed charges,38% of total billed charges,4.22,40,,230.04,percent of total billed charges,40% of total billed charges,3737.94,5389,
VAGINAL SPECULA SM,4200631,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,21.888,percent of total billed charges,38% of total billed charges,2.4,40,,230.04,percent of total billed charges,40% of total billed charges,3738.94,5390,
VAGINAL SPECULA MED.,4200632,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,14.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,21.888,percent of total billed charges,38% of total billed charges,3.6,40,,555.928,percent of total billed charges,40% of total billed charges,3739.94,5391,
VAGINAL SPECULA LG.,4200633,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,42.184,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,15.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,138.32,percent of total billed charges,38% of total billed charges,3.6,40,,38.344,percent of total billed charges,40% of total billed charges,3740.94,5392,
ATHLETIC SUPPORTER W/LEG STRAP MEDIUM,4200635,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,135.536,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,15.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,21.888,percent of total billed charges,38% of total billed charges,12,40,,123.2,percent of total billed charges,40% of total billed charges,3741.94,5393,
ATHLETIC SUPPORTER W/LEG STRAP LARGE,4200636,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,16.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,21.888,percent of total billed charges,38% of total billed charges,12,40,,230.04,percent of total billed charges,40% of total billed charges,3742.94,5394,
ATHLETIC SUPPORTER W/LEG STRAP X-LARGE,4200637,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,832.352,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,21.888,percent of total billed charges,38% of total billed charges,12,40,,756.576,percent of total billed charges,40% of total billed charges,3743.94,5395,
DOUBLE LUMEN CEN. LINE KIT 7FR,4200640,CDM,270,RC,,,OUTPATIENT,,,96,57.6,,81.6,85,,65.28,Percent of total billed charges,85% of total billed charges,48,50,,38.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48,50,,38.4,percent of total billed charges,50% of total billed charges,30.67,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,30.67,31.95,,4.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.48,38,,21.888,percent of total billed charges,38% of total billed charges,38.4,40,,74.632,percent of total billed charges,40% of total billed charges,3744.94,5396,
DOUBLE LUMEM LINE KIT 8.5FR,4200642,CDM,270,RC,,,OUTPATIENT,,,92,55.2,,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,46,50,,36.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,46,50,,36.8,percent of total billed charges,50% of total billed charges,29.39,31.95,,737.024,percent of total billed charges,31.95% of total billed charges,29.39,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.96,38,,21.888,percent of total billed charges,38% of total billed charges,36.8,40,,669.928,percent of total billed charges,40% of total billed charges,3745.94,5397,
TRIPLE LUMEN LINE KIT 12FR,4200643,CDM,270,RC,,,OUTPATIENT,,,308,184.8,,261.8,85,,209.44,Percent of total billed charges,85% of total billed charges,154,50,,123.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,154,50,,123.2,percent of total billed charges,50% of total billed charges,98.41,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,98.41,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,21.888,percent of total billed charges,38% of total billed charges,123.2,40,,920.16,percent of total billed charges,40% of total billed charges,3746.94,5398,
EXCHANGE TRANSFUSION TRAY,4200644,CDM,270,RC,,,OUTPATIENT,,,113.4,68.04,,96.39,85,,77.112,Percent of total billed charges,85% of total billed charges,56.7,50,,45.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.7,50,,45.36,percent of total billed charges,50% of total billed charges,36.23,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,36.23,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.09,38,,247.152,percent of total billed charges,38% of total billed charges,45.36,40,,421.744,percent of total billed charges,40% of total billed charges,3747.94,5399,
LUMBAR PUNCTURE TRAY 22G PEDIATRIC,4200645,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,139.84,percent of total billed charges,38% of total billed charges,2.4,40,,230.04,percent of total billed charges,40% of total billed charges,3748.94,5400,
DUO-THERM BLANKET,4200647,CDM,270,RC,,,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29,50,,23.2,percent of total billed charges,50% of total billed charges,18.53,31.95,,75.08,percent of total billed charges,31.95% of total billed charges,18.53,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.04,38,,21.888,percent of total billed charges,38% of total billed charges,23.2,40,,68.248,percent of total billed charges,40% of total billed charges,3749.94,5401,
RECTAL THERMAL PROBE 9FR,4200648,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,103.776,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,103.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,21.888,percent of total billed charges,38% of total billed charges,15.2,40,,129.92,percent of total billed charges,40% of total billed charges,3750.94,5402,
SOLIDIFIER,4200649,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.92,35.15,,107.864,percent of total billed charges,35.15% of total billed charges,126.2,31.95,,107.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,21.888,percent of total billed charges,38% of total billed charges,4.47,31.95,,135.04,percent of total billed charges,31.95% of total billed charges,3751.94,5403,
NU GAUZE IODOFOAM 1/2X5,4200650,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,322.824,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,322.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,21.888,percent of total billed charges,38% of total billed charges,4,40,,404.16,percent of total billed charges,40% of total billed charges,3752.94,5404,
HCG CONTROL,4200651,CDM,270,RC,,,OUTPATIENT,,,62,37.2,,52.7,85,,42.16,Percent of total billed charges,85% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31,50,,24.8,percent of total billed charges,50% of total billed charges,19.81,31.95,,114.256,percent of total billed charges,31.95% of total billed charges,19.81,31.95,,114.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.56,38,,21.888,percent of total billed charges,38% of total billed charges,24.8,40,,143.04,percent of total billed charges,40% of total billed charges,3753.94,5405,
NU GAUZE PLAIN 1/2''''X5,4200653,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,1136.048,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,21.888,percent of total billed charges,38% of total billed charges,4.4,40,,1032.624,percent of total billed charges,40% of total billed charges,3754.94,5406,
NU GAUZE PLAIN 1/4''''X5,4200655,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,100.104,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,21.888,percent of total billed charges,38% of total billed charges,4.4,40,,90.992,percent of total billed charges,40% of total billed charges,3755.94,5407,
NU GAUZE IODOFOAM 1/4''''X5,4200656,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,21.888,percent of total billed charges,38% of total billed charges,4.4,40,,78.728,percent of total billed charges,40% of total billed charges,3756.94,5408,
BATTERY OTOSCOPE 72200,4200657,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,21.888,percent of total billed charges,38% of total billed charges,31.2,40,,78.728,percent of total billed charges,40% of total billed charges,3757.94,5409,
NU GAUZE IODOFOAM 1X5,4200659,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,130.416,percent of total billed charges,38% of total billed charges,4,40,,78.728,percent of total billed charges,40% of total billed charges,3758.94,5410,
NU GAUZE PLAIN 1X5,4200660,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,17.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,21.888,percent of total billed charges,38% of total billed charges,6,40,,78.728,percent of total billed charges,40% of total billed charges,3759.94,5411,
COLOSTOMY STRIP,4200665,CDM,270,RC,,,OUTPATIENT,,,37.4,22.44,,31.79,85,,25.432,Percent of total billed charges,85% of total billed charges,18.7,50,,14.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.7,50,,14.96,percent of total billed charges,50% of total billed charges,11.95,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,11.95,31.95,,32.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.21,38,,21.888,percent of total billed charges,38% of total billed charges,14.96,40,,78.728,percent of total billed charges,40% of total billed charges,3760.94,5412,
COLOSTOMY KIT 1.75,4200669,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,46.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,21.888,percent of total billed charges,38% of total billed charges,5.6,40,,78.728,percent of total billed charges,40% of total billed charges,3761.94,5413,
COLOSTOMY DRAINAGE COLLECTOR,4200672,CDM,270,RC,,,OUTPATIENT,,,44.4,26.64,,37.74,85,,30.192,Percent of total billed charges,85% of total billed charges,22.2,50,,17.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.2,50,,17.76,percent of total billed charges,50% of total billed charges,14.19,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,14.19,31.95,,54.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.87,38,,21.888,percent of total billed charges,38% of total billed charges,17.76,40,,78.728,percent of total billed charges,40% of total billed charges,3762.94,5414,
COLOSTOMY FEEDING TUBE ATTACH.,4200673,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,37.12,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,57.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,21.888,percent of total billed charges,38% of total billed charges,8.8,40,,33.736,percent of total billed charges,40% of total billed charges,3763.94,5415,
COLOSTOMY CLAMP 7770,4200674,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,21.888,percent of total billed charges,38% of total billed charges,1.6,40,,9.968,percent of total billed charges,40% of total billed charges,3764.94,5416,
UROSTOMY CENTER PT 2 1/4 3912,4200676,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,10.688,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,21.888,percent of total billed charges,38% of total billed charges,24,40,,9.712,percent of total billed charges,40% of total billed charges,3765.94,5417,
T.E.D. STOCKING LARGE SHORT THIGH,4200678,CDM,270,RC,,,OUTPATIENT,,,67.38,40.428,,57.27,85,,45.816,Percent of total billed charges,85% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,21.53,31.95,,234.64,percent of total billed charges,31.95% of total billed charges,21.53,31.95,,234.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.6,38,,21.888,percent of total billed charges,38% of total billed charges,26.95,40,,293.76,percent of total billed charges,40% of total billed charges,3766.94,5418,
T.E.D. STOCKING MEDIUM SHORT THIGH,4200679,CDM,270,RC,,,OUTPATIENT,,,67.38,40.428,,57.27,85,,45.816,Percent of total billed charges,85% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,21.53,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,21.53,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.6,38,,21.888,percent of total billed charges,38% of total billed charges,26.95,40,,131.52,percent of total billed charges,40% of total billed charges,3767.94,5419,
T.E.D. STOCKING SMALL REGULAR THIGH,4200681,CDM,270,RC,,,OUTPATIENT,,,67.38,40.428,,57.27,85,,45.816,Percent of total billed charges,85% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,21.53,31.95,,790.736,percent of total billed charges,31.95% of total billed charges,21.53,31.95,,9.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.6,38,,21.888,percent of total billed charges,38% of total billed charges,26.95,40,,718.744,percent of total billed charges,40% of total billed charges,3768.94,5420,
T.E.D. STOCKING MEDIUM REGULAR THIGH,4200682,CDM,270,RC,,,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34,50,,27.2,percent of total billed charges,50% of total billed charges,21.73,31.95,,97.856,percent of total billed charges,31.95% of total billed charges,21.73,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.84,38,,21.888,percent of total billed charges,38% of total billed charges,27.2,40,,88.952,percent of total billed charges,40% of total billed charges,3769.94,5421,
T.E.D. STOCKING LARGE REGULAR THIGH,4200683,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,115.576,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,21.888,percent of total billed charges,38% of total billed charges,5.6,40,,105.048,percent of total billed charges,40% of total billed charges,3770.94,5422,
T.E.D. STOCKING XLARGE SHORT,4200684,CDM,270,RC,,,OUTPATIENT,,,28.41,17.046,,24.15,85,,19.32,Percent of total billed charges,85% of total billed charges,14.21,50,,11.368,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.21,50,,11.368,percent of total billed charges,50% of total billed charges,9.08,31.95,,97.856,percent of total billed charges,31.95% of total billed charges,9.08,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.8,38,,21.888,percent of total billed charges,38% of total billed charges,11.36,40,,88.952,percent of total billed charges,40% of total billed charges,3771.94,5423,
T.E.D. STOCKING SMALL LONG THIGH,4200685,CDM,270,RC,,,OUTPATIENT,,,67.38,40.428,,57.27,85,,45.816,Percent of total billed charges,85% of total billed charges,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.69,50,,26.952,percent of total billed charges,50% of total billed charges,21.53,31.95,,97.856,percent of total billed charges,31.95% of total billed charges,21.53,31.95,,815.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.6,38,,26.752,percent of total billed charges,38% of total billed charges,26.95,40,,88.952,percent of total billed charges,40% of total billed charges,3772.94,5424,
T.E.D. STOCKING MEDIUM LONG THIGH,4200686,CDM,270,RC,,,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34,50,,27.2,percent of total billed charges,50% of total billed charges,21.73,31.95,,919.808,percent of total billed charges,31.95% of total billed charges,21.73,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.84,38,,81.168,percent of total billed charges,38% of total billed charges,27.2,40,,836.064,percent of total billed charges,40% of total billed charges,3773.94,5425,
T.E.D. STOCKING LARGE LONG THIGH,4200687,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,19.12,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,189.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,272.08,percent of total billed charges,38% of total billed charges,16,40,,17.384,percent of total billed charges,40% of total billed charges,3774.94,5426,
BABY GLUCOSE 5% NURSEETE BLT,4200688,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,722.688,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,338.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,40.768,percent of total billed charges,38% of total billed charges,2.8,40,,656.896,percent of total billed charges,40% of total billed charges,3775.94,5427,
SPONGE GAUZE 4X4 NONSTERILE BULK 200/P,4200702,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,599.52,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,162.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,36.432,percent of total billed charges,38% of total billed charges,6,40,,544.936,percent of total billed charges,40% of total billed charges,3776.94,5428,
SPHYGMOMONOMETER CHILD MANUAL,4200703,CDM,270,RC,,,OUTPATIENT,,,79,47.4,,67.15,85,,53.72,Percent of total billed charges,85% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,25.24,31.95,,41.616,percent of total billed charges,31.95% of total billed charges,25.24,31.95,,476.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.02,38,,90.288,percent of total billed charges,38% of total billed charges,31.6,40,,37.832,percent of total billed charges,40% of total billed charges,3777.94,5429,
SPHYGMONANOMETER ADULT MANUAL,4200704,CDM,270,RC,,,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29,50,,23.2,percent of total billed charges,50% of total billed charges,18.53,31.95,,13.776,percent of total billed charges,31.95% of total billed charges,18.53,31.95,,241.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.04,38,,515.584,percent of total billed charges,38% of total billed charges,23.2,40,,12.528,percent of total billed charges,40% of total billed charges,3778.94,5430,
SPHYGMOMANOMETER LG ADULT MANU,4200705,CDM,270,RC,,,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,29.07,31.95,,706.936,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,455.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.58,38,,413.136,percent of total billed charges,38% of total billed charges,36.4,40,,642.576,percent of total billed charges,40% of total billed charges,3779.94,5431,
SPHYGMOMANOMETER GUAGE,4200706,CDM,270,RC,,,OUTPATIENT,,,48.09,28.854,,40.88,85,,32.704,Percent of total billed charges,85% of total billed charges,24.05,50,,19.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.05,50,,19.24,percent of total billed charges,50% of total billed charges,15.36,31.95,,19.12,percent of total billed charges,31.95% of total billed charges,15.36,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.27,38,,139.944,percent of total billed charges,38% of total billed charges,19.24,40,,17.384,percent of total billed charges,40% of total billed charges,3780.94,5432,
STETHOSCOPE NON-DISPOSABLE,4200707,CDM,270,RC,,,OUTPATIENT,,,23,13.8,,19.55,85,,15.64,Percent of total billed charges,85% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,7.35,31.95,,123.168,percent of total billed charges,31.95% of total billed charges,7.35,31.95,,1.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.74,38,,376.96,percent of total billed charges,38% of total billed charges,9.2,40,,111.952,percent of total billed charges,40% of total billed charges,3781.94,5433,
ELASTIC ADHESIVE BANDAGE,4200708,CDM,270,RC,,,OUTPATIENT,,,23.56,14.136,,20.03,85,,16.024,Percent of total billed charges,85% of total billed charges,11.78,50,,9.424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.78,50,,9.424,percent of total billed charges,50% of total billed charges,7.53,31.95,,39.928,percent of total billed charges,31.95% of total billed charges,7.53,31.95,,1.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.95,38,,412.832,percent of total billed charges,38% of total billed charges,9.42,40,,36.296,percent of total billed charges,40% of total billed charges,3782.94,5434,
CAST ORTHO GLASS 6''''X15FT ROLL,4200713,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,34.872,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,425.6,percent of total billed charges,38% of total billed charges,8.4,40,,31.696,percent of total billed charges,40% of total billed charges,3783.94,5435,
CAST ORTHO GLASS 4X15FT ROLL,4200714,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,246.896,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,115.52,percent of total billed charges,38% of total billed charges,5.6,40,,224.416,percent of total billed charges,40% of total billed charges,3784.94,5436,
UNIVERSAL MALE RIB BELT,4200715,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,211.464,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,1.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,99.408,percent of total billed charges,38% of total billed charges,6.4,40,,192.208,percent of total billed charges,40% of total billed charges,3785.94,5437,
CHEST RESTRAINT LG,4200716,CDM,270,RC,E0710,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,11.95,35.15,,32.616,percent of total billed charges,35.15% of total billed charges,126.2,31.95,,6.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,142.272,percent of total billed charges,38% of total billed charges,10.86,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,3786.94,5438,
CHEST RESTRAINT MED,4200717,CDM,270,RC,E0710,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,11.95,35.15,,90.264,percent of total billed charges,35.15% of total billed charges,126.2,31.95,,12.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,114.824,percent of total billed charges,38% of total billed charges,10.86,31.95,,82.048,percent of total billed charges,31.95% of total billed charges,3787.94,5439,
CHEST RESTRAINT SM,4200718,CDM,270,RC,E0710,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,11.95,35.15,,333.816,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,333.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,66.944,percent of total billed charges,38% of total billed charges,10.86,31.95,,417.92,percent of total billed charges,31.95% of total billed charges,3788.94,5440,
CERVICAL COLLAR PEDIATRIC UNIVERSAL,4200724,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,1035.376,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,22.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,190.304,percent of total billed charges,38% of total billed charges,6.8,40,,941.12,percent of total billed charges,40% of total billed charges,3789.94,5441,
KNEE IMMOBILIZER 22'''',4200725,CDM,270,RC,,,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29,50,,23.2,percent of total billed charges,50% of total billed charges,18.53,31.95,,105.728,percent of total billed charges,31.95% of total billed charges,18.53,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.04,38,,209.76,percent of total billed charges,38% of total billed charges,23.2,40,,96.104,percent of total billed charges,40% of total billed charges,3790.94,5442,
SPORTS ANKLE BRACE LL,4200726,CDM,270,RC,,,OUTPATIENT,,,42.6,25.56,,36.21,85,,28.968,Percent of total billed charges,85% of total billed charges,21.3,50,,17.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.3,50,,17.04,percent of total billed charges,50% of total billed charges,13.61,31.95,,97.856,percent of total billed charges,31.95% of total billed charges,13.61,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.19,38,,52.712,percent of total billed charges,38% of total billed charges,17.04,40,,88.952,percent of total billed charges,40% of total billed charges,3791.94,5443,
SPORTS ANKLE BRACE LR,4200727,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,97.856,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,60.28,percent of total billed charges,38% of total billed charges,18,40,,88.952,percent of total billed charges,40% of total billed charges,3792.94,5444,
SPORTS ANKLE BRACE ML,4200728,CDM,270,RC,,,OUTPATIENT,,,42.6,25.56,,36.21,85,,28.968,Percent of total billed charges,85% of total billed charges,21.3,50,,17.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.3,50,,17.04,percent of total billed charges,50% of total billed charges,13.61,31.95,,1088.248,percent of total billed charges,31.95% of total billed charges,13.61,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.19,38,,328.32,percent of total billed charges,38% of total billed charges,17.04,40,,989.176,percent of total billed charges,40% of total billed charges,3793.94,5445,
POST. TIB-FIB SPLINT YOUTH,4200731,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,61,36.6,,51.85,85,,41.48,Percent of total billed charges,85% of total billed charges,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,21.44,35.15,,129.592,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,129.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.18,38,,91.2,percent of total billed charges,38% of total billed charges,19.49,31.95,,162.24,percent of total billed charges,31.95% of total billed charges,3794.94,5446,
POST. TIB-FIB SPLINT CHILD,4200732,CDM,270,RC,,,OUTPATIENT,,,77,46.2,,65.45,85,,52.36,Percent of total billed charges,85% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,24.6,31.95,,127.544,percent of total billed charges,31.95% of total billed charges,24.6,31.95,,127.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.26,38,,121.6,percent of total billed charges,38% of total billed charges,30.8,40,,159.68,percent of total billed charges,40% of total billed charges,3795.94,5447,
POST. TIB-FIB SPLINT 15.75'''' ADULT,4200733,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,19.4,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,7.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,122.816,percent of total billed charges,38% of total billed charges,36,40,,17.64,percent of total billed charges,40% of total billed charges,3796.94,5448,
POST. TIB-FIB SPLINT 31'''' ADULT,4200734,CDM,270,RC,,,OUTPATIENT,,,114,68.4,,96.9,85,,77.52,Percent of total billed charges,85% of total billed charges,57,50,,45.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57,50,,45.6,percent of total billed charges,50% of total billed charges,36.42,31.95,,19.4,percent of total billed charges,31.95% of total billed charges,36.42,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.32,38,,106.4,percent of total billed charges,38% of total billed charges,45.6,40,,17.64,percent of total billed charges,40% of total billed charges,3797.94,5449,
CLAVICAL STRAP ADULT,4200736,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,19.4,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,92.112,percent of total billed charges,38% of total billed charges,16,40,,17.64,percent of total billed charges,40% of total billed charges,3798.94,5450,
PERFOR. COCKUP WRIST SPLINT SL,4200737,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,95.76,percent of total billed charges,38% of total billed charges,14,40,,74.632,percent of total billed charges,40% of total billed charges,3799.94,5451,
PERFOR. COCKUP WRIST SPLINT SR,4200738,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,22.16,percent of total billed charges,38% of total billed charges,14,40,,421.744,percent of total billed charges,40% of total billed charges,3800.94,5452,
PERFOR. COCKUP WRIST SPLINT ML,4200739,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,2116.032,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,16.6,percent of total billed charges,38% of total billed charges,13.2,40,,1923.392,percent of total billed charges,40% of total billed charges,3801.94,5453,
PERFOR. COCKUP WRIST SPLINT MR,4200740,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,210.904,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,16.872,percent of total billed charges,38% of total billed charges,14,40,,191.704,percent of total billed charges,40% of total billed charges,3802.94,5454,
PERFOR. COCKUP WRIST SPLINT LL,4200741,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,1511.448,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,16.872,percent of total billed charges,38% of total billed charges,13.2,40,,1373.848,percent of total billed charges,40% of total billed charges,3803.94,5455,
PERFOR. COCKUP WRIST SPLINT LR,4200742,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,68.048,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,1672,percent of total billed charges,38% of total billed charges,14,40,,61.856,percent of total billed charges,40% of total billed charges,3804.94,5456,
PERFOR. COCKUP WRIST SPLINT XLL,4200743,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,68.048,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,820.8,percent of total billed charges,38% of total billed charges,13.2,40,,61.856,percent of total billed charges,40% of total billed charges,3805.94,5457,
PERFOR. COCKUP WRIST SPLINT XLR,4200744,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,547.2,percent of total billed charges,38% of total billed charges,13.2,40,,498.424,percent of total billed charges,40% of total billed charges,3806.94,5458,
COLLES SPLINT SMALL R,4200745,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,516.8,percent of total billed charges,38% of total billed charges,17.2,40,,120,percent of total billed charges,40% of total billed charges,3807.94,5459,
COLLES SPLINT MEDIUM L,4200746,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,759.24,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,1672,percent of total billed charges,38% of total billed charges,17.2,40,,690.12,percent of total billed charges,40% of total billed charges,3808.94,5460,
COLLES SPLINT MEDIUM R,4200747,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,379.624,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,3.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,820.8,percent of total billed charges,38% of total billed charges,17.2,40,,345.064,percent of total billed charges,40% of total billed charges,3809.94,5461,
COLLES SPLINT LARGE L,4200748,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,47.24,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,5.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,547.2,percent of total billed charges,38% of total billed charges,17.6,40,,42.944,percent of total billed charges,40% of total billed charges,3810.94,5462,
COLLES SPLINT LARGE R,4200749,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,1680.168,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,5.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,516.8,percent of total billed charges,38% of total billed charges,17.2,40,,1527.208,percent of total billed charges,40% of total billed charges,3811.94,5463,
SHOULDER IMMOBILIZER WOMEN SM,4200750,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,210.904,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,1641.6,percent of total billed charges,38% of total billed charges,12.8,40,,191.704,percent of total billed charges,40% of total billed charges,3812.94,5464,
SHOULDER IMMOBILIZER WOMEN LG,4200751,CDM,270,RC,A4565,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,12.3,35.15,,1203.536,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,10.51,100,,,fee schedule,100% of CMS custom fee schedule,13.3,38,,1003.2,percent of total billed charges,38% of total billed charges,11.18,31.95,,1093.968,percent of total billed charges,31.95% of total billed charges,3813.94,5465,
SHOULDER IMMOBILIZER MEN LG,4200752,CDM,270,RC,A4565,HCPCS,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,11.6,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,10.51,100,,,fee schedule,100% of CMS custom fee schedule,12.54,38,,1185.6,percent of total billed charges,38% of total billed charges,10.54,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,3814.94,5466,
ARM SLING XLG,4200754,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,111.072,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,729.6,percent of total billed charges,38% of total billed charges,4,40,,100.96,percent of total billed charges,40% of total billed charges,3815.94,5467,
NEBULIZER 760ML STERILE WATER W/O ADAPTER,4200755,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,126.544,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,8.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,316.464,percent of total billed charges,38% of total billed charges,4,40,,115.024,percent of total billed charges,40% of total billed charges,3816.94,5468,
CLAVICLE SPLINT PADDED MED.,4200756,CDM,270,RC,,,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,102.144,percent of total billed charges,38% of total billed charges,9.6,40,,28.8,percent of total billed charges,40% of total billed charges,3817.94,5469,
CLAVICLE SPLINT PADDED LG,4200757,CDM,270,RC,,,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,837.976,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,9.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,81.168,percent of total billed charges,38% of total billed charges,9.6,40,,761.688,percent of total billed charges,40% of total billed charges,3818.94,5470,
CLAVICLE SPLINT PADDED XL,4200758,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,19.4,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,81.168,percent of total billed charges,38% of total billed charges,10.8,40,,17.64,percent of total billed charges,40% of total billed charges,3819.94,5471,
"POST-OP SHOE, VELCRO MEN SM",4200759,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,19.4,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,81.168,percent of total billed charges,38% of total billed charges,11.2,40,,17.64,percent of total billed charges,40% of total billed charges,3820.94,5472,
"POST-OP SHOE, VELCRO MEN MED.",4200760,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,93.936,percent of total billed charges,38% of total billed charges,10.8,40,,78.728,percent of total billed charges,40% of total billed charges,3821.94,5473,
"POST-OP SHOE, VELCRO MEN LG",4200761,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,93.936,percent of total billed charges,38% of total billed charges,11.6,40,,78.728,percent of total billed charges,40% of total billed charges,3822.94,5474,
"POST-OP SHOE, VELCRO WOMEN SM",4200762,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,93.936,percent of total billed charges,38% of total billed charges,11.6,40,,78.728,percent of total billed charges,40% of total billed charges,3823.94,5475,
"POST-OP SHOE, VELCRO WOMEN MED",4200763,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,450.528,percent of total billed charges,38% of total billed charges,11.2,40,,78.728,percent of total billed charges,40% of total billed charges,3824.94,5476,
"POST-OP SHOE, VELCRO WOMEN LG",4200764,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,102.144,percent of total billed charges,38% of total billed charges,11.2,40,,78.728,percent of total billed charges,40% of total billed charges,3825.94,5477,
"MONITOR PAPER, BLANK ROLL",4200765,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,81.168,percent of total billed charges,38% of total billed charges,1.6,40,,78.728,percent of total billed charges,40% of total billed charges,3826.94,5478,
NEEDLE SHORT PEN ULTRAFINEIII,4200769,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,579.424,percent of total billed charges,38% of total billed charges,37.6,40,,78.728,percent of total billed charges,40% of total billed charges,3827.94,5479,
DEFIBULATOR ELECTRODE ADULT (M3501A),4200771,CDM,270,RC,,,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.5,50,,22,percent of total billed charges,50% of total billed charges,17.57,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.9,38,,86.64,percent of total billed charges,38% of total billed charges,22,40,,421.744,percent of total billed charges,40% of total billed charges,3828.94,5480,
MONITOR LEAD (HOLTER HEART MONITORS),4200772,CDM,270,RC,,,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,60,50,,48,percent of total billed charges,50% of total billed charges,38.34,31.95,,273.888,percent of total billed charges,31.95% of total billed charges,38.34,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.6,38,,120.688,percent of total billed charges,38% of total billed charges,48,40,,248.952,percent of total billed charges,40% of total billed charges,3829.94,5481,
RED DOT MONITOR ELECTRODE 50PK,4200773,CDM,270,RC,,,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,10.4,percent of total billed charges,50% of total billed charges,8.31,31.95,,139.472,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,31.008,percent of total billed charges,38% of total billed charges,10.4,40,,126.776,percent of total billed charges,40% of total billed charges,3830.94,5482,
RED DOT MONITOR ELECTRODE 50PK (NUC. MED),4200774,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,506.16,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,240.768,percent of total billed charges,38% of total billed charges,3.2,40,,460.08,percent of total billed charges,40% of total billed charges,3831.94,5483,
ELECTRODE PEDIATRIC 50PK,4200775,CDM,270,RC,,,OUTPATIENT,,,7.7,4.62,,6.55,85,,5.24,Percent of total billed charges,85% of total billed charges,3.85,50,,3.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.85,50,,3.08,percent of total billed charges,50% of total billed charges,2.46,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,2.46,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.93,38,,226.176,percent of total billed charges,38% of total billed charges,3.08,40,,498.424,percent of total billed charges,40% of total billed charges,3832.94,5484,
CABLE SENSOR DATASCOPE,4200776,CDM,270,RC,,,OUTPATIENT,,,270,162,,229.5,85,,183.6,Percent of total billed charges,85% of total billed charges,135,50,,108,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,135,50,,108,percent of total billed charges,50% of total billed charges,86.27,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,86.27,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.6,38,,180.576,percent of total billed charges,38% of total billed charges,108,40,,498.424,percent of total billed charges,40% of total billed charges,3833.94,5485,
TELEMETRY POUCH,4200778,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,180.576,percent of total billed charges,38% of total billed charges,2.8,40,,555.928,percent of total billed charges,40% of total billed charges,3834.94,5486,
SURGI CUFF SM ADULT LL,4200779,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,1560.664,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,27.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,1641.6,percent of total billed charges,38% of total billed charges,6.4,40,,1418.584,percent of total billed charges,40% of total billed charges,3835.94,5487,
SURGI CUFF CHILD RECTUS,4200780,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,56.24,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,36.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,1003.2,percent of total billed charges,38% of total billed charges,6,40,,51.12,percent of total billed charges,40% of total billed charges,3836.94,5488,
SURGI CUFF ADULT LL,4200781,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,350.096,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,45.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,1185.6,percent of total billed charges,38% of total billed charges,6.4,40,,318.224,percent of total billed charges,40% of total billed charges,3837.94,5489,
SURGI CUFF LG ADULT LL,4200782,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,108.632,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,108.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,157.776,percent of total billed charges,38% of total billed charges,6.4,40,,136,percent of total billed charges,40% of total billed charges,3838.94,5490,
SURGI CUFF THIGH BAYONET,4200783,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,1112.144,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,57.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,1216,percent of total billed charges,38% of total billed charges,6,40,,1010.896,percent of total billed charges,40% of total billed charges,3839.94,5491,
THOCAR CATHETER 24FR,4200790,CDM,270,RC,,,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37,50,,29.6,percent of total billed charges,50% of total billed charges,23.64,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,23.64,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.12,38,,912,percent of total billed charges,38% of total billed charges,29.6,40,,78.728,percent of total billed charges,40% of total billed charges,3840.94,5492,
THOCAR THORACIC CATHETER 28FR,4200793,CDM,270,RC,,,OUTPATIENT,,,62.85,37.71,,53.42,85,,42.736,Percent of total billed charges,85% of total billed charges,31.43,50,,25.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.43,50,,25.144,percent of total billed charges,50% of total billed charges,20.08,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,20.08,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.88,38,,96.672,percent of total billed charges,38% of total billed charges,25.14,40,,78.728,percent of total billed charges,40% of total billed charges,3841.94,5493,
20FR 5CC COUDET 0102L20,4200798,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,86.608,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,912,percent of total billed charges,38% of total billed charges,16,40,,78.728,percent of total billed charges,40% of total billed charges,3842.94,5494,
22FR 5CC COUDET 0102L22,4200799,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,1520,percent of total billed charges,38% of total billed charges,16,40,,174.4,percent of total billed charges,40% of total billed charges,3843.94,5495,
24FR 5CC COUDET 0102L24,4200800,CDM,270,RC,,,OUTPATIENT,,,39.45,23.67,,33.53,85,,26.824,Percent of total billed charges,85% of total billed charges,19.73,50,,15.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.73,50,,15.784,percent of total billed charges,50% of total billed charges,12.6,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,12.6,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.99,38,,912,percent of total billed charges,38% of total billed charges,15.78,40,,555.928,percent of total billed charges,40% of total billed charges,3844.94,5496,
22FR 5CC 3-WAY 0119L22,4200801,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,611.608,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,3.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,912,percent of total billed charges,38% of total billed charges,13.2,40,,555.928,percent of total billed charges,40% of total billed charges,3845.94,5497,
10FR 3CC RIBBED 0165L10,4200802,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,1560.664,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,96.672,percent of total billed charges,38% of total billed charges,8.8,40,,1418.584,percent of total billed charges,40% of total billed charges,3846.94,5498,
12FR 5CC 0165L12,4200803,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,393.68,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,117.344,percent of total billed charges,38% of total billed charges,8.8,40,,357.84,percent of total billed charges,40% of total billed charges,3847.94,5499,
14FR 5CC RIBBED 0165L14,4200804,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,393.68,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,1368,percent of total billed charges,38% of total billed charges,8.4,40,,357.84,percent of total billed charges,40% of total billed charges,3848.94,5500,
16FR 5CC FOLEY (1616),4200805,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,545.528,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,5.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,912,percent of total billed charges,38% of total billed charges,8.8,40,,495.864,percent of total billed charges,40% of total billed charges,3849.94,5501,
18FR 5CC FOLEY (1619),4200806,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,988,percent of total billed charges,38% of total billed charges,8.4,40,,498.424,percent of total billed charges,40% of total billed charges,3850.94,5502,
20FR 5CC 0165L20,4200807,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,1010.912,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,120.688,percent of total billed charges,38% of total billed charges,8.8,40,,918.88,percent of total billed charges,40% of total billed charges,3851.94,5503,
22FR 5CC RIBBED 0165L22,4200808,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,253.08,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,1368,percent of total billed charges,38% of total billed charges,8.8,40,,230.04,percent of total billed charges,40% of total billed charges,3852.94,5504,
24FR 5CC RIBBED 0165L24,4200809,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,918.96,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,988,percent of total billed charges,38% of total billed charges,8.8,40,,835.304,percent of total billed charges,40% of total billed charges,3853.94,5505,
26FR 5CC 0165L26,4200810,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,918.96,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,13.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,456,percent of total billed charges,38% of total billed charges,8.8,40,,835.304,percent of total billed charges,40% of total billed charges,3854.94,5506,
30FR 5CC 0165L30,4200811,CDM,270,RC,,,OUTPATIENT,,,27.2,16.32,,23.12,85,,18.496,Percent of total billed charges,85% of total billed charges,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,8.69,31.95,,918.96,percent of total billed charges,31.95% of total billed charges,8.69,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.34,38,,44.08,percent of total billed charges,38% of total billed charges,10.88,40,,835.304,percent of total billed charges,40% of total billed charges,3855.94,5507,
8FR 5CC 0165PL08,4200812,CDM,270,RC,,,OUTPATIENT,,,25.6,15.36,,21.76,85,,17.408,Percent of total billed charges,85% of total billed charges,12.8,50,,10.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.8,50,,10.24,percent of total billed charges,50% of total billed charges,8.18,31.95,,918.96,percent of total billed charges,31.95% of total billed charges,8.18,31.95,,101.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.73,38,,493.392,percent of total billed charges,38% of total billed charges,10.24,40,,835.304,percent of total billed charges,40% of total billed charges,3856.94,5508,
CATHETER FOLEY 10FR 3CC PEDIATRIC LF,4200813,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,803.672,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,1094.4,percent of total billed charges,38% of total billed charges,14,40,,730.504,percent of total billed charges,40% of total billed charges,3857.94,5509,
24FR 30CC RIBBED 0166L24,4200818,CDM,270,RC,,,OUTPATIENT,,,27.2,16.32,,23.12,85,,18.496,Percent of total billed charges,85% of total billed charges,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,8.69,31.95,,803.672,percent of total billed charges,31.95% of total billed charges,8.69,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.34,38,,48.336,percent of total billed charges,38% of total billed charges,10.88,40,,730.504,percent of total billed charges,40% of total billed charges,3858.94,5510,
26FR 30CC RIBBED 0166L26,4200819,CDM,270,RC,,,OUTPATIENT,,,27.2,16.32,,23.12,85,,18.496,Percent of total billed charges,85% of total billed charges,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,8.69,31.95,,83.8,percent of total billed charges,31.95% of total billed charges,8.69,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.34,38,,75.392,percent of total billed charges,38% of total billed charges,10.88,40,,76.168,percent of total billed charges,40% of total billed charges,3859.94,5511,
30FR 30CC RIBBED 0166L30,4200820,CDM,270,RC,,,OUTPATIENT,,,27.2,16.32,,23.12,85,,18.496,Percent of total billed charges,85% of total billed charges,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,8.69,31.95,,867.504,percent of total billed charges,31.95% of total billed charges,8.69,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.34,38,,35.264,percent of total billed charges,38% of total billed charges,10.88,40,,788.528,percent of total billed charges,40% of total billed charges,3860.94,5512,
16FR 3-WAY 30CC 0167L16,4200821,CDM,270,RC,,,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,22.37,31.95,,39.368,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.6,38,,1466.192,percent of total billed charges,38% of total billed charges,28,40,,35.784,percent of total billed charges,40% of total billed charges,3861.94,5513,
18FR 3-WAY 0167L18,4200822,CDM,270,RC,,,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,11.82,31.95,,39.368,percent of total billed charges,31.95% of total billed charges,11.82,31.95,,608.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.06,38,,2103.072,percent of total billed charges,38% of total billed charges,14.8,40,,35.784,percent of total billed charges,40% of total billed charges,3862.94,5514,
20FR 3-WAY 0167L20,4200823,CDM,270,RC,,,OUTPATIENT,,,42.9,25.74,,36.47,85,,29.176,Percent of total billed charges,85% of total billed charges,21.45,50,,17.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.45,50,,17.16,percent of total billed charges,50% of total billed charges,13.71,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,13.71,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.3,38,,1094.4,percent of total billed charges,38% of total billed charges,17.16,40,,74.632,percent of total billed charges,40% of total billed charges,3863.94,5515,
22FR 3-WAY 0167L22,4200824,CDM,270,RC,,,OUTPATIENT,,,42.9,25.74,,36.47,85,,29.176,Percent of total billed charges,85% of total billed charges,21.45,50,,17.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.45,50,,17.16,percent of total billed charges,50% of total billed charges,13.71,31.95,,82.112,percent of total billed charges,31.95% of total billed charges,13.71,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.3,38,,547.2,percent of total billed charges,38% of total billed charges,17.16,40,,74.632,percent of total billed charges,40% of total billed charges,3864.94,5516,
24FR 3-WAY 0167L24,4200825,CDM,270,RC,,,OUTPATIENT,,,37.5,22.5,,31.88,85,,25.504,Percent of total billed charges,85% of total billed charges,18.75,50,,15,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.75,50,,15,percent of total billed charges,50% of total billed charges,11.98,31.95,,850.352,percent of total billed charges,31.95% of total billed charges,11.98,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.25,38,,501.6,percent of total billed charges,38% of total billed charges,15,40,,772.936,percent of total billed charges,40% of total billed charges,3865.94,5517,
26FR 30CC 3-WAY 0167L26,4200826,CDM,270,RC,,,OUTPATIENT,,,50.7,30.42,,43.1,85,,34.48,Percent of total billed charges,85% of total billed charges,25.35,50,,20.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.35,50,,20.28,percent of total billed charges,50% of total billed charges,16.2,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,16.2,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.27,38,,194.56,percent of total billed charges,38% of total billed charges,20.28,40,,15.336,percent of total billed charges,40% of total billed charges,3866.94,5518,
SPECIMEN BAGS 6X9,4200834,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,18.56,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,117.344,percent of total billed charges,38% of total billed charges,4.4,40,,16.872,percent of total billed charges,40% of total billed charges,3867.94,5519,
FACESHIELD (FULL LENGTH),4200835,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1110.744,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,163.856,percent of total billed charges,38% of total billed charges,2.8,40,,1009.624,percent of total billed charges,40% of total billed charges,3868.94,5520,
KANGAROO TOP FILL BAG (SINGLE BAG),4200838,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,56.8,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,110.352,percent of total billed charges,38% of total billed charges,4.8,40,,51.632,percent of total billed charges,40% of total billed charges,3869.94,5521,
SODIUM CHLORIDE 10ML BOTTLE FLUSH,4200840,CDM,270,RC,,,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,10.86,31.95,,484.224,percent of total billed charges,31.95% of total billed charges,10.86,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,92.416,percent of total billed charges,38% of total billed charges,13.6,40,,440.144,percent of total billed charges,40% of total billed charges,3870.94,5522,
STERILE WATER 10ML FLUSH,4200841,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,1060.352,percent of total billed charges,38% of total billed charges,11.2,40,,498.424,percent of total billed charges,40% of total billed charges,3871.94,5523,
ARMBOARD INFANT,4200844,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.7,35.15,,850.352,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,1060.352,percent of total billed charges,38% of total billed charges,0.64,31.95,,772.936,percent of total billed charges,31.95% of total billed charges,3872.94,5524,
AUTOGUARD INSYTE 18GX1.16,4200845,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,820.8,percent of total billed charges,38% of total billed charges,3.6,40,,15.336,percent of total billed charges,40% of total billed charges,3873.94,5525,
NITRO IV SET,4200846,CDM,270,RC,,,OUTPATIENT,,,36.08,21.648,,30.67,85,,24.536,Percent of total billed charges,85% of total billed charges,18.04,50,,14.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.04,50,,14.432,percent of total billed charges,50% of total billed charges,11.53,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,11.53,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.71,38,,592.8,percent of total billed charges,38% of total billed charges,14.43,40,,498.424,percent of total billed charges,40% of total billed charges,3874.94,5526,
CRUTCHES CHILD,4200847,CDM,270,RC,E0112,HCPCS,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,22.14,35.15,,89.144,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,106.4,percent of total billed charges,38% of total billed charges,20.13,31.95,,81.024,percent of total billed charges,31.95% of total billed charges,3875.94,5527,
BABY DIAPER SZ 1 INFANT 12PK/CS,4200848,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,790.736,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,107.92,percent of total billed charges,38% of total billed charges,7.6,40,,718.744,percent of total billed charges,40% of total billed charges,3876.94,5528,
EZ SCRUB W/ CHG 4%,4200850,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,115.856,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,106.4,percent of total billed charges,38% of total billed charges,18,40,,105.304,percent of total billed charges,40% of total billed charges,3877.94,5529,
SPONGE X-RAY DETECTABLE 10S,4200852,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,182.4,percent of total billed charges,38% of total billed charges,2,40,,421.744,percent of total billed charges,40% of total billed charges,3878.94,5530,
SHOE COVER XL ANTISKID,4200853,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,490.696,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,190,percent of total billed charges,38% of total billed charges,8.8,40,,446.024,percent of total billed charges,40% of total billed charges,3879.94,5531,
LAPAROSCOPY/PELVISCOPY DRAPE,4200856,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,91.2,percent of total billed charges,38% of total billed charges,12,40,,498.424,percent of total billed charges,40% of total billed charges,3880.94,5532,
LAP PELVIS PACK III 5/CS,4200858,CDM,270,RC,,,OUTPATIENT,,,79,47.4,,67.15,85,,53.72,Percent of total billed charges,85% of total billed charges,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39.5,50,,31.6,percent of total billed charges,50% of total billed charges,25.24,31.95,,1744.848,percent of total billed charges,31.95% of total billed charges,25.24,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.02,38,,179.36,percent of total billed charges,38% of total billed charges,31.6,40,,1586,percent of total billed charges,40% of total billed charges,3881.94,5533,
ANESTHESIA BREATHING CIRCUIT ADULT,4200861,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,1012.32,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,30.4,percent of total billed charges,38% of total billed charges,15.2,40,,920.16,percent of total billed charges,40% of total billed charges,3882.94,5534,
UNDERBUTTOCK DRAPE,4200862,CDM,270,RC,,,OUTPATIENT,,,8.3,4.98,,7.06,85,,5.648,Percent of total billed charges,85% of total billed charges,4.15,50,,3.32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.15,50,,3.32,percent of total billed charges,50% of total billed charges,2.65,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,2.65,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.15,38,,115.52,percent of total billed charges,38% of total billed charges,3.32,40,,498.424,percent of total billed charges,40% of total billed charges,3883.94,5535,
DRAPE EXTRA LARGE 20/CS,4200863,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,815.48,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,212.8,percent of total billed charges,38% of total billed charges,6,40,,741.24,percent of total billed charges,40% of total billed charges,3884.94,5536,
EXIDINE 4 PREOP SKIN PREP TRAY,4200867,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,17.328,percent of total billed charges,38% of total billed charges,4.4,40,,498.424,percent of total billed charges,40% of total billed charges,3885.94,5537,
SHARPS CONTAINER 8GL. RED,4200873,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,75.928,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,592.8,percent of total billed charges,38% of total billed charges,17.2,40,,69.016,percent of total billed charges,40% of total billed charges,3886.94,5538,
PRESENTATION PORTFOLIO 2 POCKET NAVY,4200874,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,155.92,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,155.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,273.6,percent of total billed charges,38% of total billed charges,6,40,,195.2,percent of total billed charges,40% of total billed charges,3887.94,5539,
GLOVE STERILE 8,4200877,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.7,35.15,,1512.856,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,547.2,percent of total billed charges,38% of total billed charges,0.64,31.95,,1375.128,percent of total billed charges,31.95% of total billed charges,3888.94,5540,
BATTERY 9 VOLT,4200880,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,51.176,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,501.6,percent of total billed charges,38% of total billed charges,1.6,40,,46.52,percent of total billed charges,40% of total billed charges,3889.94,5541,
GLUCOMETER STRIPS,4200881,CDM,270,RC,,,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,51.176,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.3,38,,273.6,percent of total billed charges,38% of total billed charges,34,40,,46.52,percent of total billed charges,40% of total billed charges,3890.94,5542,
GLUCOMETER SOLUTION NORMAL,4200882,CDM,270,RC,,,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,10.4,percent of total billed charges,50% of total billed charges,8.31,31.95,,51.176,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,273.6,percent of total billed charges,38% of total billed charges,10.4,40,,46.52,percent of total billed charges,40% of total billed charges,3891.94,5543,
GLUCOMETER SOLUTION HIGH,4200883,CDM,270,RC,,,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,12.46,31.95,,51.176,percent of total billed charges,31.95% of total billed charges,12.46,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.82,38,,145.92,percent of total billed charges,38% of total billed charges,15.6,40,,46.52,percent of total billed charges,40% of total billed charges,3892.94,5544,
SYRINGE INSULIN .5ML LO DOSE,4200884,CDM,270,RC,,,OUTPATIENT,,,93,55.8,,79.05,85,,63.24,Percent of total billed charges,85% of total billed charges,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,46.5,50,,37.2,percent of total billed charges,50% of total billed charges,29.71,31.95,,29.136,percent of total billed charges,31.95% of total billed charges,29.71,31.95,,29.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.34,38,,820.8,percent of total billed charges,38% of total billed charges,37.2,40,,36.48,percent of total billed charges,40% of total billed charges,3893.94,5545,
NEEDLE SPINAL 22G X 3.5'''',4200886,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.81,35.15,,113.888,percent of total billed charges,35.15% of total billed charges,126.84,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,273.6,percent of total billed charges,38% of total billed charges,2.56,31.95,,103.52,percent of total billed charges,31.95% of total billed charges,3894.94,5546,
FMC NEEDLE SPINAL 22GX3.5,4200886,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,106.4,percent of total billed charges,38% of total billed charges,3.2,40,,498.424,percent of total billed charges,40% of total billed charges,3895.94,5547,
FMC SPINAL NEEDLE 22GX3.5'''',4200886,CDM,270,RC,A4215,HCPCS,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.81,35.15,,136.488,percent of total billed charges,35.15% of total billed charges,127.16,31.95,,136.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,17.328,percent of total billed charges,38% of total billed charges,2.56,31.95,,170.88,percent of total billed charges,31.95% of total billed charges,3896.94,5548,
NEEDLE SPINAL 18G X 3.5'''',4200887,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,101.728,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,101.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,17.328,percent of total billed charges,38% of total billed charges,3.2,40,,127.36,percent of total billed charges,40% of total billed charges,3897.94,5549,
INTRACATH 14G/16G,4200888,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,149.272,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,149.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,638.4,percent of total billed charges,38% of total billed charges,15.2,40,,186.88,percent of total billed charges,40% of total billed charges,3898.94,5550,
INTRACATH 17G/19G,4200889,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,122.432,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,122.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,592.8,percent of total billed charges,38% of total billed charges,15.2,40,,153.28,percent of total billed charges,40% of total billed charges,3899.94,5551,
INTRCATH 20G/22G,4200890,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,100.392,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,505.248,percent of total billed charges,38% of total billed charges,15.2,40,,91.248,percent of total billed charges,40% of total billed charges,3900.94,5552,
ANGIOCATH 16G,4200891,CDM,270,RC,,,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,16.29,31.95,,100.392,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.38,38,,445.056,percent of total billed charges,38% of total billed charges,20.4,40,,91.248,percent of total billed charges,40% of total billed charges,3901.94,5553,
DIAPER XLARGE ADULT BREATHABLE,4200893,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,1.824,percent of total billed charges,38% of total billed charges,8.4,40,,498.424,percent of total billed charges,40% of total billed charges,3902.94,5554,
OPSITE 10X5.5,4200894,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,111.952,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,111.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,1.824,percent of total billed charges,38% of total billed charges,3.2,40,,140.16,percent of total billed charges,40% of total billed charges,3903.94,5555,
SHILEY TRACH CUFFED 6LPC,4200897,CDM,270,RC,A7521,HCPCS,OUTPATIENT,,,123,73.8,,104.55,85,,83.64,Percent of total billed charges,85% of total billed charges,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,61.5,50,,49.2,percent of total billed charges,50% of total billed charges,43.23,35.15,,37.12,percent of total billed charges,35.15% of total billed charges,1278,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,64.19,100,,,fee schedule,100% of CMS custom fee schedule,46.74,38,,21.28,percent of total billed charges,38% of total billed charges,39.3,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,3904.94,5556,
PROBE COVER  WELCHALLYN,4200898,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,82.672,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,117.952,percent of total billed charges,38% of total billed charges,1.2,40,,75.144,percent of total billed charges,40% of total billed charges,3905.94,5557,
FILTER W/INJECTION SITE,4200900,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,82.672,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,568.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,76,percent of total billed charges,38% of total billed charges,6.4,40,,75.144,percent of total billed charges,40% of total billed charges,3906.94,5558,
STERI-DRAPE 31X51,4200903,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,82.672,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,39.52,percent of total billed charges,38% of total billed charges,5.6,40,,75.144,percent of total billed charges,40% of total billed charges,3907.94,5559,
MASK TIE ON,4200905,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,95.888,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,480.32,percent of total billed charges,38% of total billed charges,17.2,40,,87.16,percent of total billed charges,40% of total billed charges,3908.94,5560,
CAP TIE ON,4200906,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,338.848,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,501.6,percent of total billed charges,38% of total billed charges,11.6,40,,308,percent of total billed charges,40% of total billed charges,3909.94,5561,
MASK PROCEDURAL,4200907,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,636.88,percent of total billed charges,38% of total billed charges,5.6,40,,421.744,percent of total billed charges,40% of total billed charges,3910.94,5562,
TELEPHONE PATIENT,4200908,CDM,270,RC,,,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,13.42,31.95,,717.064,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,501.6,percent of total billed charges,38% of total billed charges,16.8,40,,651.784,percent of total billed charges,40% of total billed charges,3911.94,5563,
BLADE MYRINGOTOMY,4200909,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,548.344,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,45.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,182.4,percent of total billed charges,38% of total billed charges,16,40,,498.424,percent of total billed charges,40% of total billed charges,3912.94,5564,
DIAPER MEDIUM ADULT BREATHABLE,4200913,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,267.424,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,97.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,91.2,percent of total billed charges,38% of total billed charges,8,40,,243.072,percent of total billed charges,40% of total billed charges,3913.94,5565,
"SPLINT, FINGER 3'' PADDED",4200914,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,114,percent of total billed charges,38% of total billed charges,3.6,40,,126.4,percent of total billed charges,40% of total billed charges,3914.94,5566,
"SPLINT, FINGER 3.5'''' PADDED",4200915,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,1287.896,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,1068.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,1094.4,percent of total billed charges,38% of total billed charges,3.6,40,,1170.648,percent of total billed charges,40% of total billed charges,3915.94,5567,
CUVETTES HB201+MACHINE,4200916,CDM,270,RC,,,OUTPATIENT,,,342,205.2,,290.7,85,,232.56,Percent of total billed charges,85% of total billed charges,171,50,,136.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,171,50,,136.8,percent of total billed charges,50% of total billed charges,109.27,31.95,,107.984,percent of total billed charges,31.95% of total billed charges,109.27,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.96,38,,547.2,percent of total billed charges,38% of total billed charges,136.8,40,,98.152,percent of total billed charges,40% of total billed charges,3916.94,5568,
SHEATH THERMOMETER PROBE,4200919,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,107.984,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,48.336,percent of total billed charges,38% of total billed charges,4,40,,98.152,percent of total billed charges,40% of total billed charges,3917.94,5569,
EGG CRATE MATTRESS,4200920,CDM,270,RC,,,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,13.1,31.95,,107.984,percent of total billed charges,31.95% of total billed charges,13.1,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.58,38,,85.12,percent of total billed charges,38% of total billed charges,16.4,40,,98.152,percent of total billed charges,40% of total billed charges,3918.94,5570,
BLADE CLIPPER SURGICAL,4200922,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,107.984,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,88.768,percent of total billed charges,38% of total billed charges,5.6,40,,98.152,percent of total billed charges,40% of total billed charges,3919.94,5571,
SHILEY TRACH 3NEO NEONATE,4200925,CDM,270,RC,A7520,HCPCS,OUTPATIENT,,,85.5,51.3,,72.68,85,,58.144,Percent of total billed charges,85% of total billed charges,42.75,50,,34.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.75,50,,34.2,percent of total billed charges,50% of total billed charges,30.05,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,1284.39,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,64.78,100,,,fee schedule,100% of CMS custom fee schedule,32.49,38,,88.768,percent of total billed charges,38% of total billed charges,27.32,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,3920.94,5572,
PCA INJECTOR W/O TUBING,4200932,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,107.984,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,114.912,percent of total billed charges,38% of total billed charges,4,40,,98.152,percent of total billed charges,40% of total billed charges,3921.94,5573,
NEEDLE INTRAOSSEOUS NEEDLE 18G,4200934,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,107.984,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,85.12,percent of total billed charges,38% of total billed charges,18,40,,98.152,percent of total billed charges,40% of total billed charges,3922.94,5574,
CATHETER COUDE  RED RIB 18FR,4200940,CDM,270,RC,,,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,16.29,31.95,,1679.888,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.38,38,,85.12,percent of total billed charges,38% of total billed charges,20.4,40,,1526.952,percent of total billed charges,40% of total billed charges,3923.94,5575,
SENSOR O2 FINGER REUSABLE,4200942,CDM,270,RC,,,OUTPATIENT,,,263,157.8,,223.55,85,,178.84,Percent of total billed charges,85% of total billed charges,131.5,50,,105.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,131.5,50,,105.2,percent of total billed charges,50% of total billed charges,84.03,31.95,,349.528,percent of total billed charges,31.95% of total billed charges,84.03,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,99.94,38,,699.2,percent of total billed charges,38% of total billed charges,105.2,40,,317.712,percent of total billed charges,40% of total billed charges,3924.94,5576,
HAIR BRUSH,4200944,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,210.904,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,5.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,120.688,percent of total billed charges,38% of total billed charges,0.8,40,,191.704,percent of total billed charges,40% of total billed charges,3925.94,5577,
"SPLINT, FINGER 18'' PADDED",4200947,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,463.984,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,6.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,48.336,percent of total billed charges,38% of total billed charges,3.2,40,,421.744,percent of total billed charges,40% of total billed charges,3926.94,5578,
SUPRAPUBIC CATHETER SET,4200954,CDM,270,RC,,,OUTPATIENT,,,226,135.6,,192.1,85,,153.68,Percent of total billed charges,85% of total billed charges,113,50,,90.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,113,50,,90.4,percent of total billed charges,50% of total billed charges,72.21,31.95,,399.304,percent of total billed charges,31.95% of total billed charges,72.21,31.95,,7.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,85.88,38,,63.84,percent of total billed charges,38% of total billed charges,90.4,40,,362.952,percent of total billed charges,40% of total billed charges,3927.94,5579,
CATHETER 16FR ALL PURPOSE RED,4200955,CDM,270,RC,,,OUTPATIENT,,,1.6,0.96,,1.36,85,,1.088,Percent of total billed charges,85% of total billed charges,0.8,50,,0.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.8,50,,0.64,percent of total billed charges,50% of total billed charges,0.51,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,0.51,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.61,38,,182.4,percent of total billed charges,38% of total billed charges,0.64,40,,195.84,percent of total billed charges,40% of total billed charges,3928.94,5580,
DIAPERS XXXL BARIATRIC BREATHABLE,4200958,CDM,270,RC,,,OUTPATIENT,,,52,31.2,,44.2,85,,35.36,Percent of total billed charges,85% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26,50,,20.8,percent of total billed charges,50% of total billed charges,16.61,31.95,,466.232,percent of total billed charges,31.95% of total billed charges,16.61,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.76,38,,1094.4,percent of total billed charges,38% of total billed charges,20.8,40,,423.784,percent of total billed charges,40% of total billed charges,3929.94,5581,
CATHETER 10FR ALL PURPOSE RED,4200960,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,501.6,percent of total billed charges,38% of total billed charges,2.8,40,,17.6,percent of total billed charges,40% of total billed charges,3930.94,5582,
CATHETER 14FR ALL PURPOSE RED,4200961,CDM,270,RC,,,OUTPATIENT,,,67.75,40.65,,57.59,85,,46.072,Percent of total billed charges,85% of total billed charges,33.88,50,,27.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.88,50,,27.104,percent of total billed charges,50% of total billed charges,21.65,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,21.65,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.75,38,,6.992,percent of total billed charges,38% of total billed charges,27.1,40,,11.2,percent of total billed charges,40% of total billed charges,3931.94,5583,
DIAPER XXL ADULT BREATHABLE,4200967,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,168.112,percent of total billed charges,38% of total billed charges,8.4,40,,35.2,percent of total billed charges,40% of total billed charges,3932.94,5584,
STOCKINETTE COTTON 6''''X25YDS,4200969,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,17.024,percent of total billed charges,38% of total billed charges,1.2,40,,30.4,percent of total billed charges,40% of total billed charges,3933.94,5585,
TOURNIQUET LATEX FREE,4200972,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,17.024,percent of total billed charges,38% of total billed charges,17.6,40,,24.96,percent of total billed charges,40% of total billed charges,3934.94,5586,
ABDOMINAL BINDER 9'''',4200973,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,27.664,percent of total billed charges,38% of total billed charges,12,40,,96,percent of total billed charges,40% of total billed charges,3935.94,5587,
PILL BAG,4200976,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,7.032,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,1.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,27.664,percent of total billed charges,38% of total billed charges,4.4,40,,6.392,percent of total billed charges,40% of total billed charges,3936.94,5588,
DRESSING EXTRA ALGINATE (MAXORB),4200979,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,22.496,percent of total billed charges,38% of total billed charges,5.6,40,,42.88,percent of total billed charges,40% of total billed charges,3937.94,5589,
DRESSING FOAM 6X6 ALLEVYN,4200980,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,22.496,percent of total billed charges,38% of total billed charges,12.8,40,,42.88,percent of total billed charges,40% of total billed charges,3938.94,5590,
DURODERM THIN 3X3 HYDROCOLLOID (REPLICARE),4200981,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,22.496,percent of total billed charges,38% of total billed charges,8.4,40,,50.24,percent of total billed charges,40% of total billed charges,3939.94,5591,
DRESSING THIN 4X4 ALLEVYN,4200982,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,22.496,percent of total billed charges,38% of total billed charges,4.8,40,,50.24,percent of total billed charges,40% of total billed charges,3940.94,5592,
AQUACEL FOAM SILVER DRESSING 4''''X4'''',4200983,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,27.352,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,27.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,288.8,percent of total billed charges,38% of total billed charges,4.4,40,,34.24,percent of total billed charges,40% of total billed charges,3941.94,5593,
DRESSING PLUS CAVITY 4X4,4200984,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,6.08,percent of total billed charges,38% of total billed charges,5.6,40,,53.76,percent of total billed charges,40% of total billed charges,3942.94,5594,
DRESSING HEEL OPTIFOAM,4200985,CDM,270,RC,,,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,11.82,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,11.82,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.06,38,,17.632,percent of total billed charges,38% of total billed charges,14.8,40,,73.6,percent of total billed charges,40% of total billed charges,3943.94,5595,
GEL HYDROGEL TUBE 3OZ SOLOSITE,4200986,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,93.632,percent of total billed charges,38% of total billed charges,11.2,40,,27.2,percent of total billed charges,40% of total billed charges,3944.94,5596,
DRESSING DURODERM 6X6 X-THIN (REPLICARE),4200987,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,145.008,percent of total billed charges,38% of total billed charges,16,40,,27.2,percent of total billed charges,40% of total billed charges,3945.94,5597,
CLEANSER PERSONNAL 8OZ SECURA,4200991,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,969.76,percent of total billed charges,38% of total billed charges,3.2,40,,18.88,percent of total billed charges,40% of total billed charges,3946.94,5598,
PROTECTANT DIMETHICONE SECURA,4200992,CDM,270,RC,,,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,10.4,percent of total billed charges,50% of total billed charges,8.31,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,113.392,percent of total billed charges,38% of total billed charges,10.4,40,,28.16,percent of total billed charges,40% of total billed charges,3947.94,5599,
EXTRA SKIN PROTECTANT CREAM,4200993,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,86.64,percent of total billed charges,38% of total billed charges,8.8,40,,48.64,percent of total billed charges,40% of total billed charges,3948.94,5600,
CREAM MOISTURIZING SECURA 3OZ,4200994,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,113.392,percent of total billed charges,38% of total billed charges,4.4,40,,36.8,percent of total billed charges,40% of total billed charges,3949.94,5601,
CREAM ANTIFUNGAL EXTRA THICK,4200995,CDM,270,RC,,,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,13.42,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,146.528,percent of total billed charges,38% of total billed charges,16.8,40,,47.68,percent of total billed charges,40% of total billed charges,3950.94,5602,
SYRINGE 60CC ST,4200996,CDM,270,RC,,,OUTPATIENT,,,1.7,1.02,,1.45,85,,1.16,Percent of total billed charges,85% of total billed charges,0.85,50,,0.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.85,50,,0.68,percent of total billed charges,50% of total billed charges,0.54,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,0.54,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.65,38,,136.8,percent of total billed charges,38% of total billed charges,0.68,40,,3.024,percent of total billed charges,40% of total billed charges,3951.94,5603,
CURETTE CERASPOON EAR YELLOW,4200998,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,40.896,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,40.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,42.56,percent of total billed charges,38% of total billed charges,2,40,,51.2,percent of total billed charges,40% of total billed charges,3952.94,5604,
SPO2 ADULT SENSOR DISPOSABLE,4200999,CDM,270,RC,,,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,10.86,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,10.86,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,144.704,percent of total billed charges,38% of total billed charges,13.6,40,,2.416,percent of total billed charges,40% of total billed charges,3953.94,5605,
SPO2 PEDIATRIC SENSOR DISP.,4201000,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,224.656,percent of total billed charges,38% of total billed charges,12.8,40,,92.8,percent of total billed charges,40% of total billed charges,3954.94,5606,
SPO2 INFANT SENSOR DISPOSABLE,4201001,CDM,270,RC,,,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,20.13,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,20.13,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,144.704,percent of total billed charges,38% of total billed charges,25.2,40,,64,percent of total billed charges,40% of total billed charges,3955.94,5607,
SPO2 NEONATE SENSOR DISPOSABLE,4201002,CDM,270,RC,,,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,20.13,31.95,,56.24,percent of total billed charges,31.95% of total billed charges,20.13,31.95,,2.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,35.264,percent of total billed charges,38% of total billed charges,25.2,40,,51.12,percent of total billed charges,40% of total billed charges,3956.94,5608,
VACUTAINER TUBE PURPLE TOP 3ML,4201004,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,180.272,percent of total billed charges,38% of total billed charges,12,40,,3.024,percent of total billed charges,40% of total billed charges,3957.94,5609,
VACUTAINER TUBE RED/GRAY TOP 3ML,4201005,CDM,270,RC,,,OUTPATIENT,,,62,37.2,,52.7,85,,42.16,Percent of total billed charges,85% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31,50,,24.8,percent of total billed charges,50% of total billed charges,19.81,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,19.81,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.56,38,,89.376,percent of total billed charges,38% of total billed charges,24.8,40,,6.4,percent of total billed charges,40% of total billed charges,3958.94,5610,
VACUTAINER TUBE RED TOP 30ML,4201007,CDM,270,RC,,,OUTPATIENT,,,31,18.6,,26.35,85,,21.08,Percent of total billed charges,85% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,9.9,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,9.9,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.78,38,,152,percent of total billed charges,38% of total billed charges,12.4,40,,4.872,percent of total billed charges,40% of total billed charges,3959.94,5611,
VACUTAINER TUBE BLUE TOP 2.7ML,4201008,CDM,270,RC,,,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,10.86,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,10.86,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,138.32,percent of total billed charges,38% of total billed charges,13.6,40,,3.024,percent of total billed charges,40% of total billed charges,3960.94,5612,
CURETTE LOOP WHITE,4201009,CDM,270,RC,,,OUTPATIENT,,,40.85,24.51,,34.72,85,,27.776,Percent of total billed charges,85% of total billed charges,20.43,50,,16.344,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.43,50,,16.344,percent of total billed charges,50% of total billed charges,13.05,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,13.05,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.52,38,,35.264,percent of total billed charges,38% of total billed charges,16.34,40,,3.024,percent of total billed charges,40% of total billed charges,3961.94,5613,
KLEENEX TISSUE LARGE BOX,4201010,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1103.52,percent of total billed charges,38% of total billed charges,1.6,40,,20.8,percent of total billed charges,40% of total billed charges,3962.94,5614,
DRAPE SHEET 40X48 CLINICS,4201011,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,41.664,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,41.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,44.688,percent of total billed charges,38% of total billed charges,18.4,40,,52.16,percent of total billed charges,40% of total billed charges,3963.94,5615,
ELEPHANT EAR WASHER TIP,4201012,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,56.544,percent of total billed charges,38% of total billed charges,17.6,40,,103.04,percent of total billed charges,40% of total billed charges,3964.94,5616,
BACTI-STAT HAND LOTION 1000ML,4201013,CDM,270,RC,,,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,56.544,percent of total billed charges,38% of total billed charges,9.6,40,,27.2,percent of total billed charges,40% of total billed charges,3965.94,5617,
ENT PACK SURGICAL,4201015,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,87,52.2,,73.95,85,,59.16,Percent of total billed charges,85% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,30.58,35.15,,6.136,percent of total billed charges,35.15% of total billed charges,1290.78,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.06,38,,56.544,percent of total billed charges,38% of total billed charges,27.8,31.95,,7.68,percent of total billed charges,31.95% of total billed charges,3966.94,5618,
INKJET CARTRIDGE CANON 221 4 COLORS,4201016,CDM,270,RC,A4340,HCPCS,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.92,35.15,,33.736,percent of total billed charges,35.15% of total billed charges,1437.75,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,39.51,100,,,fee schedule,100% of CMS custom fee schedule,5.32,38,,10.032,percent of total billed charges,38% of total billed charges,4.47,31.95,,42.24,percent of total billed charges,31.95% of total billed charges,3967.94,5619,
GLOVE EXAM X-SMALL NITRAL,4201023,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,17.936,percent of total billed charges,38% of total billed charges,11.6,40,,28.16,percent of total billed charges,40% of total billed charges,3968.94,5620,
GLOVE EXAM SMALL NITRAL,4201024,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,35.872,percent of total billed charges,38% of total billed charges,14,40,,16,percent of total billed charges,40% of total billed charges,3969.94,5621,
GLOVE EXAM LARGE NITRAL,4201025,CDM,270,RC,,,OUTPATIENT,,,31,18.6,,26.35,85,,21.08,Percent of total billed charges,85% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,9.9,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,9.9,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.78,38,,1231.2,percent of total billed charges,38% of total billed charges,12.4,40,,14.72,percent of total billed charges,40% of total billed charges,3970.94,5622,
GLOVE EXAM X-LARGE NITRAL,4201026,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,592.8,percent of total billed charges,38% of total billed charges,11.6,40,,7.68,percent of total billed charges,40% of total billed charges,3971.94,5623,
TAPE REGISTER THERMAL 3'''',4201028,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,592.8,percent of total billed charges,38% of total billed charges,6,40,,7.68,percent of total billed charges,40% of total billed charges,3972.94,5624,
CRD CANISTERS,4201032,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,505.248,percent of total billed charges,38% of total billed charges,11.2,40,,6.4,percent of total billed charges,40% of total billed charges,3973.94,5625,
MIC-KEY 24FR FEEDING TUBE,4201035,CDM,270,RC,,,OUTPATIENT,,,192,115.2,,163.2,85,,130.56,Percent of total billed charges,85% of total billed charges,96,50,,76.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96,50,,76.8,percent of total billed charges,50% of total billed charges,61.34,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,61.34,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,72.96,38,,1231.2,percent of total billed charges,38% of total billed charges,76.8,40,,27.2,percent of total billed charges,40% of total billed charges,3974.94,5626,
SCALPEL BLADE #15,4201039,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,83.072,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,83.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,775.2,percent of total billed charges,38% of total billed charges,1.2,40,,104,percent of total billed charges,40% of total billed charges,3975.94,5627,
SCALPEL BLADE #21,4201040,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,65.688,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,65.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,592.8,percent of total billed charges,38% of total billed charges,1.6,40,,82.24,percent of total billed charges,40% of total billed charges,3976.94,5628,
WRAP STERILIZATION 40''''X40'''',4201041,CDM,270,RC,,,OUTPATIENT,,,202,121.2,,171.7,85,,137.36,Percent of total billed charges,85% of total billed charges,101,50,,80.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,101,50,,80.8,percent of total billed charges,50% of total billed charges,64.54,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,64.54,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76.76,38,,273.6,percent of total billed charges,38% of total billed charges,80.8,40,,103.04,percent of total billed charges,40% of total billed charges,3977.94,5629,
POUCH STERILIZATION 3.5''''X22'''',4201044,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,13.68,percent of total billed charges,38% of total billed charges,31.2,40,,32,percent of total billed charges,40% of total billed charges,3978.94,5630,
STEAM CHEMICAL INTERGRATOR,4201045,CDM,270,RC,,,OUTPATIENT,,,54,32.4,,45.9,85,,36.72,Percent of total billed charges,85% of total billed charges,27,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27,50,,21.6,percent of total billed charges,50% of total billed charges,17.25,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,17.25,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.52,38,,152,percent of total billed charges,38% of total billed charges,21.6,40,,74.88,percent of total billed charges,40% of total billed charges,3979.94,5631,
LABEL NEW MEDICATION ORDERS,4201046,CDM,270,RC,,,OUTPATIENT,,,159,95.4,,135.15,85,,108.12,Percent of total billed charges,85% of total billed charges,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79.5,50,,63.6,percent of total billed charges,50% of total billed charges,50.8,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,50.8,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.42,38,,152,percent of total billed charges,38% of total billed charges,63.6,40,,32,percent of total billed charges,40% of total billed charges,3980.94,5632,
RIBBON NR72 CALCULATOR,4201050,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,41.152,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,41.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,212.8,percent of total billed charges,38% of total billed charges,5.2,40,,51.52,percent of total billed charges,40% of total billed charges,3981.94,5633,
OSTOMY BAG  2.25'''',4201051,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,49.328,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,49.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,82.08,percent of total billed charges,38% of total billed charges,2.4,40,,61.76,percent of total billed charges,40% of total billed charges,3982.94,5634,
BULB OTOSCOPE 06300,4201052,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,158.08,percent of total billed charges,38% of total billed charges,18,40,,54.4,percent of total billed charges,40% of total billed charges,3983.94,5635,
BULB OTOSCOPE 07800,4201053,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,152,percent of total billed charges,38% of total billed charges,17.2,40,,48.64,percent of total billed charges,40% of total billed charges,3984.94,5636,
BULB VAGINAL LIGHT 08800-U,4201054,CDM,270,RC,,,OUTPATIENT,,,64,38.4,,54.4,85,,43.52,Percent of total billed charges,85% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32,50,,25.6,percent of total billed charges,50% of total billed charges,20.45,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,20.45,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.32,38,,1231.2,percent of total billed charges,38% of total billed charges,25.6,40,,5.112,percent of total billed charges,40% of total billed charges,3985.94,5637,
BULB OTOSCOPE 03000,4201055,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,775.2,percent of total billed charges,38% of total billed charges,18.4,40,,2.56,percent of total billed charges,40% of total billed charges,3986.94,5638,
BULB OTOSCOPE 03100,4201056,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,11.528,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,592.8,percent of total billed charges,38% of total billed charges,18.4,40,,10.48,percent of total billed charges,40% of total billed charges,3987.94,5639,
LABEL HIGH RISK FALL,4201066,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,273.6,percent of total billed charges,38% of total billed charges,17.2,40,,3.064,percent of total billed charges,40% of total billed charges,3988.94,5640,
LABEL DOCTOR WHITE SOLID SPOON,4201071,CDM,270,RC,,,OUTPATIENT,,,249,149.4,,211.65,85,,169.32,Percent of total billed charges,85% of total billed charges,124.5,50,,99.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,124.5,50,,99.6,percent of total billed charges,50% of total billed charges,79.56,31.95,,3.472,percent of total billed charges,31.95% of total billed charges,79.56,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,94.62,38,,1094.4,percent of total billed charges,38% of total billed charges,99.6,40,,3.16,percent of total billed charges,40% of total billed charges,3989.94,5641,
FOREHEAD TEMPERATURE STRIP,4201075,CDM,270,RC,,,OUTPATIENT,,,172,103.2,,146.2,85,,116.96,Percent of total billed charges,85% of total billed charges,86,50,,68.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,86,50,,68.8,percent of total billed charges,50% of total billed charges,54.95,31.95,,6.752,percent of total billed charges,31.95% of total billed charges,54.95,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,65.36,38,,547.2,percent of total billed charges,38% of total billed charges,68.8,40,,6.136,percent of total billed charges,40% of total billed charges,3990.94,5642,
COVER MAINTENANCE 16X30 SELF SEAL,4201080,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,26.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,501.6,percent of total billed charges,38% of total billed charges,6,40,,2.56,percent of total billed charges,40% of total billed charges,3991.94,5643,
GLOVE STERILE SURGICAL LF 6,4201082,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,501.6,percent of total billed charges,38% of total billed charges,2.8,40,,2.56,percent of total billed charges,40% of total billed charges,3992.94,5644,
T.E.D. STOCKING SM SHORT THIGH,4201084,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,12.656,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,109.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,76,percent of total billed charges,38% of total billed charges,16,40,,11.504,percent of total billed charges,40% of total billed charges,3993.94,5645,
DEFIBRILLATOR PAD (PHILLIPS) ADULT M3716A,4201086,CDM,270,RC,,,OUTPATIENT,,,67,40.2,,56.95,85,,45.56,Percent of total billed charges,85% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,21.41,31.95,,52.656,percent of total billed charges,31.95% of total billed charges,21.41,31.95,,52.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.46,38,,592.8,percent of total billed charges,38% of total billed charges,26.8,40,,65.92,percent of total billed charges,40% of total billed charges,3994.94,5646,
"BITE STICK, PLASTIC",4201090,CDM,270,RC,,,OUTPATIENT,,,2.95,1.77,,2.51,85,,2.008,Percent of total billed charges,85% of total billed charges,1.48,50,,1.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.48,50,,1.184,percent of total billed charges,50% of total billed charges,0.94,31.95,,73.616,percent of total billed charges,31.95% of total billed charges,0.94,31.95,,73.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.12,38,,1094.4,percent of total billed charges,38% of total billed charges,1.18,40,,92.16,percent of total billed charges,40% of total billed charges,3995.94,5647,
INKJET CARTRIDGE BX-3,4201091,CDM,270,RC,,,OUTPATIENT,,,20.25,12.15,,17.21,85,,13.768,Percent of total billed charges,85% of total billed charges,10.13,50,,8.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.13,50,,8.104,percent of total billed charges,50% of total billed charges,6.47,31.95,,144.672,percent of total billed charges,31.95% of total billed charges,6.47,31.95,,144.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.7,38,,501.6,percent of total billed charges,38% of total billed charges,8.1,40,,181.12,percent of total billed charges,40% of total billed charges,3996.94,5648,
MORGAN LENS,4201107,CDM,270,RC,,,OUTPATIENT,,,76,45.6,,64.6,85,,51.68,Percent of total billed charges,85% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38,50,,30.4,percent of total billed charges,50% of total billed charges,24.28,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,24.28,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.88,38,,197.6,percent of total billed charges,38% of total billed charges,30.4,40,,115.2,percent of total billed charges,40% of total billed charges,3997.94,5649,
HUBER NEEDLE W/TUBING 20GX..75,4201108,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,10.64,percent of total billed charges,38% of total billed charges,12.8,40,,81.6,percent of total billed charges,40% of total billed charges,3998.94,5650,
SHILEY TRACH CUFFED 8LPC,4201109,CDM,270,RC,,,OUTPATIENT,,,103,61.8,,87.55,85,,70.04,Percent of total billed charges,85% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,32.91,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,32.91,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.14,38,,12.16,percent of total billed charges,38% of total billed charges,41.2,40,,47.68,percent of total billed charges,40% of total billed charges,3999.94,5651,
WRAP STERILIZATION 48X48,4201110,CDM,270,RC,,,OUTPATIENT,,,246,147.6,,209.1,85,,167.28,Percent of total billed charges,85% of total billed charges,123,50,,98.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,123,50,,98.4,percent of total billed charges,50% of total billed charges,78.6,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,78.6,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,93.48,38,,30.4,percent of total billed charges,38% of total billed charges,98.4,40,,31.36,percent of total billed charges,40% of total billed charges,4000.94,5652,
LEAD 5 WIRE DATASCOPE DPM6,4201115,CDM,270,RC,,,OUTPATIENT,,,141,84.6,,119.85,85,,95.88,Percent of total billed charges,85% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,45.05,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,45.05,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.58,38,,592.8,percent of total billed charges,38% of total billed charges,56.4,40,,105.28,percent of total billed charges,40% of total billed charges,4001.94,5653,
HIGHLIGHTER YELLOW FLUORESCENT,4201119,CDM,270,RC,,,OUTPATIENT,,,472.94,283.764,,402,85,,321.6,Percent of total billed charges,85% of total billed charges,236.47,50,,189.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,236.47,50,,189.176,percent of total billed charges,50% of total billed charges,151.1,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,151.1,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,179.72,38,,273.6,percent of total billed charges,38% of total billed charges,189.18,40,,25.6,percent of total billed charges,40% of total billed charges,4002.94,5654,
RUBBERBAND #33,4201123,CDM,270,RC,,,OUTPATIENT,,,525.6,315.36,,446.76,85,,357.408,Percent of total billed charges,85% of total billed charges,262.8,50,,210.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,262.8,50,,210.24,percent of total billed charges,50% of total billed charges,167.93,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,167.93,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,199.73,38,,820.8,percent of total billed charges,38% of total billed charges,210.24,40,,19.2,percent of total billed charges,40% of total billed charges,4003.94,5655,
POUCH STERILIZATION 8''''X16'''',4201127,CDM,270,RC,,,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,31.95,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38,38,,547.2,percent of total billed charges,38% of total billed charges,40,40,,69.12,percent of total billed charges,40% of total billed charges,4004.94,5656,
LARYNGOSCOPE BLADE MACINTOSH #4 DISPOSABLE,4201132,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,228,percent of total billed charges,38% of total billed charges,6,40,,48.96,percent of total billed charges,40% of total billed charges,4005.94,5657,
"UA MULTI TEST STRIP (CLINICS, LAB) EXCL COLVI",4201136,CDM,270,RC,,,OUTPATIENT,,,107,64.2,,90.95,85,,72.76,Percent of total billed charges,85% of total billed charges,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,34.19,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,34.19,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.66,38,,51.072,percent of total billed charges,38% of total billed charges,42.8,40,,32,percent of total billed charges,40% of total billed charges,4006.94,5658,
STERI-DRAPE 15X15,4201137,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,48.336,percent of total billed charges,38% of total billed charges,3.2,40,,32,percent of total billed charges,40% of total billed charges,4007.94,5659,
TAPE STEAM 3M,4201138,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,34.96,percent of total billed charges,38% of total billed charges,4.8,40,,32,percent of total billed charges,40% of total billed charges,4008.94,5660,
DRESSING ISLAND ADHESIVE 4X8,4201142,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,51.376,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,51.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,775.2,percent of total billed charges,38% of total billed charges,2,40,,64.32,percent of total billed charges,40% of total billed charges,4009.94,5661,
WAFER SURFIT COLOSTOMY 2.25'''',4201148,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,273.6,percent of total billed charges,38% of total billed charges,2.8,40,,54.4,percent of total billed charges,40% of total billed charges,4010.94,5662,
MULTIFIRE GIA30-2.5,4201159,CDM,270,RC,,,OUTPATIENT,,,375.81,225.486,,319.44,85,,255.552,Percent of total billed charges,85% of total billed charges,187.91,50,,150.328,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,187.91,50,,150.328,percent of total billed charges,50% of total billed charges,120.07,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,120.07,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,142.81,38,,4.56,percent of total billed charges,38% of total billed charges,150.32,40,,48.64,percent of total billed charges,40% of total billed charges,4011.94,5663,
PETROLEUM GUAZE 3X9,4201162,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,6.08,percent of total billed charges,38% of total billed charges,1.6,40,,56,percent of total billed charges,40% of total billed charges,4012.94,5664,
STAPLER RELOAD UNIT CARTRIDGE,4201166,CDM,270,RC,,,OUTPATIENT,,,63.47,38.082,,53.95,85,,43.16,Percent of total billed charges,85% of total billed charges,31.74,50,,25.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.74,50,,25.392,percent of total billed charges,50% of total billed charges,20.28,31.95,,48.568,percent of total billed charges,31.95% of total billed charges,20.28,31.95,,48.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.12,38,,1094.4,percent of total billed charges,38% of total billed charges,25.39,40,,60.8,percent of total billed charges,40% of total billed charges,4013.94,5665,
BATTERY OTOSCOPE/OTHOMASCOPE 72300,4201167,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,1231.2,percent of total billed charges,38% of total billed charges,18,40,,48.64,percent of total billed charges,40% of total billed charges,4014.94,5666,
UA CONTROL QUANT METRIX,4201168,CDM,270,RC,,,OUTPATIENT,,,218,130.8,,185.3,85,,148.24,Percent of total billed charges,85% of total billed charges,109,50,,87.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,109,50,,87.2,percent of total billed charges,50% of total billed charges,69.65,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,69.65,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.84,38,,1231.2,percent of total billed charges,38% of total billed charges,87.2,40,,44.16,percent of total billed charges,40% of total billed charges,4015.94,5667,
GAS SAMPLING LINE,4201169,CDM,270,RC,,,OUTPATIENT,,,116,69.6,,98.6,85,,78.88,Percent of total billed charges,85% of total billed charges,58,50,,46.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,58,50,,46.4,percent of total billed charges,50% of total billed charges,37.06,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,37.06,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.08,38,,638.4,percent of total billed charges,38% of total billed charges,46.4,40,,36.8,percent of total billed charges,40% of total billed charges,4016.94,5668,
UROSTOMY BAG,4201173,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,592.8,percent of total billed charges,38% of total billed charges,3.2,40,,36.8,percent of total billed charges,40% of total billed charges,4017.94,5669,
LABEL CHART ''''E'''',4201177,CDM,270,RC,,,OUTPATIENT,,,180,108,,153,85,,122.4,Percent of total billed charges,85% of total billed charges,90,50,,72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90,50,,72,percent of total billed charges,50% of total billed charges,57.51,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,57.51,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.4,38,,273.6,percent of total billed charges,38% of total billed charges,72,40,,3.024,percent of total billed charges,40% of total billed charges,4018.94,5670,
TUBE CAPILLARY,4201178,CDM,270,RC,,,OUTPATIENT,,,67,40.2,,56.95,85,,45.56,Percent of total billed charges,85% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,21.41,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,21.41,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.46,38,,1094.4,percent of total billed charges,38% of total billed charges,26.8,40,,48,percent of total billed charges,40% of total billed charges,4019.94,5671,
RAPID RHINO ANTERIOR SM PEDI,4201179,CDM,270,RC,,,OUTPATIENT,,,76,45.6,,64.6,85,,51.68,Percent of total billed charges,85% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38,50,,30.4,percent of total billed charges,50% of total billed charges,24.28,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,24.28,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.88,38,,1094.4,percent of total billed charges,38% of total billed charges,30.4,40,,21.12,percent of total billed charges,40% of total billed charges,4020.94,5672,
RAPID RHINO ANTERIOR ADULT,4201180,CDM,270,RC,,,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,55,50,,44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,55,50,,44,percent of total billed charges,50% of total billed charges,35.15,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,35.15,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.8,38,,501.6,percent of total billed charges,38% of total billed charges,44,40,,54.4,percent of total billed charges,40% of total billed charges,4021.94,5673,
RAPID RHINO ANTERIOR COPD,4201181,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,6.08,percent of total billed charges,38% of total billed charges,36,40,,25.6,percent of total billed charges,40% of total billed charges,4022.94,5674,
RAPID RHINO POSTERIOR/ANTERIOR,4201182,CDM,270,RC,,,OUTPATIENT,,,140,84,,119,85,,95.2,Percent of total billed charges,85% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,70,50,,56,percent of total billed charges,50% of total billed charges,44.73,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,44.73,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,5.168,percent of total billed charges,38% of total billed charges,56,40,,1.92,percent of total billed charges,40% of total billed charges,4023.94,5675,
RAPID-PAC DEVICE NON-INFLAT,4201183,CDM,270,RC,,,OUTPATIENT,,,107,64.2,,90.95,85,,72.76,Percent of total billed charges,85% of total billed charges,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,53.5,50,,42.8,percent of total billed charges,50% of total billed charges,34.19,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,34.19,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,40.66,38,,3.8,percent of total billed charges,38% of total billed charges,42.8,40,,6.72,percent of total billed charges,40% of total billed charges,4024.94,5676,
NEEDLE VACUTAINER BLOOD 22G X 1.25'''',4201184,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,4.56,percent of total billed charges,38% of total billed charges,18.8,40,,28.8,percent of total billed charges,40% of total billed charges,4025.94,5677,
B/P CUFF REUSE INFANT RECTUS,4201187,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,182.4,percent of total billed charges,38% of total billed charges,15.2,40,,25.6,percent of total billed charges,40% of total billed charges,4026.94,5678,
CIDEX OPA TEST STRIP,4201188,CDM,270,RC,,,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,84,50,,67.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,84,50,,67.2,percent of total billed charges,50% of total billed charges,53.68,31.95,,58.024,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,58.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.84,38,,273.6,percent of total billed charges,38% of total billed charges,67.2,40,,72.64,percent of total billed charges,40% of total billed charges,4027.94,5679,
DISPOSABLE STETHOSCOPE,4201189,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,592.8,percent of total billed charges,38% of total billed charges,6.8,40,,16.64,percent of total billed charges,40% of total billed charges,4028.94,5680,
CURETTE INFANT BLUE,4201190,CDM,270,RC,,,OUTPATIENT,,,124,74.4,,105.4,85,,84.32,Percent of total billed charges,85% of total billed charges,62,50,,49.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,62,50,,49.6,percent of total billed charges,50% of total billed charges,39.62,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,39.62,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.12,38,,638.4,percent of total billed charges,38% of total billed charges,49.6,40,,106.24,percent of total billed charges,40% of total billed charges,4029.94,5681,
PILLOW CASE,4201194,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,592.8,percent of total billed charges,38% of total billed charges,0.8,40,,99.84,percent of total billed charges,40% of total billed charges,4030.94,5682,
ARM SLING XSM,4201200,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,59.552,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,59.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,3.8,percent of total billed charges,38% of total billed charges,4,40,,74.56,percent of total billed charges,40% of total billed charges,4031.94,5683,
URETERAL SHEATH ACCESS 12FR 35CM,4201203,CDM,270,RC,,,OUTPATIENT,,,360,216,,306,85,,244.8,Percent of total billed charges,85% of total billed charges,180,50,,144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,180,50,,144,percent of total billed charges,50% of total billed charges,115.02,31.95,,63.648,percent of total billed charges,31.95% of total billed charges,115.02,31.95,,63.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,136.8,38,,1231.2,percent of total billed charges,38% of total billed charges,144,40,,79.68,percent of total billed charges,40% of total billed charges,4032.94,5684,
B/P CUFF THIGH QUICK CONNECT,4201204,CDM,270,RC,,,OUTPATIENT,,,71,42.6,,60.35,85,,48.28,Percent of total billed charges,85% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,22.68,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,22.68,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.98,38,,1231.2,percent of total billed charges,38% of total billed charges,28.4,40,,17.6,percent of total billed charges,40% of total billed charges,4033.94,5685,
EMERY BOARD,4201205,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,228,percent of total billed charges,38% of total billed charges,12,40,,37.44,percent of total billed charges,40% of total billed charges,4034.94,5686,
ARM SLING SM,4201206,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,43.776,percent of total billed charges,38% of total billed charges,3.6,40,,35.2,percent of total billed charges,40% of total billed charges,4035.94,5687,
PLASMABUTTON 12/30 DEGREE,4201208,CDM,270,RC,,,OUTPATIENT,,,1600,960,,1360,85,,1088,Percent of total billed charges,85% of total billed charges,800,50,,640,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,800,50,,640,percent of total billed charges,50% of total billed charges,511.2,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,511.2,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,608,38,,638.4,percent of total billed charges,38% of total billed charges,640,40,,19.2,percent of total billed charges,40% of total billed charges,4036.94,5688,
NEEDLE SAFE 21GX1 305915,4201209,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,638.4,percent of total billed charges,38% of total billed charges,18.4,40,,56,percent of total billed charges,40% of total billed charges,4037.94,5689,
GEL IODOSORB IODINE 40G TUBE,4201210,CDM,270,RC,A6251,HCPCS,OUTPATIENT,,,167,100.2,,141.95,85,,113.56,Percent of total billed charges,85% of total billed charges,83.5,50,,66.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,83.5,50,,66.8,percent of total billed charges,50% of total billed charges,58.7,35.15,,35.784,percent of total billed charges,35.15% of total billed charges,1437.75,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,2.71,100,,,fee schedule,100% of CMS custom fee schedule,63.46,38,,10.032,percent of total billed charges,38% of total billed charges,53.36,31.95,,44.8,percent of total billed charges,31.95% of total billed charges,4038.94,5690,
HF LOOP LARGE 30 DEGREE SEA,4201212,CDM,270,RC,,,OUTPATIENT,,,1525,915,,1296.25,85,,1037,Percent of total billed charges,85% of total billed charges,762.5,50,,610,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,762.5,50,,610,percent of total billed charges,50% of total billed charges,487.24,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,487.24,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,579.5,38,,12.16,percent of total billed charges,38% of total billed charges,610,40,,48.64,percent of total billed charges,40% of total billed charges,4039.94,5691,
AUTOGURAD INSYTE 16GX1.16,4201213,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,3.16,35.15,,25.048,percent of total billed charges,35.15% of total billed charges,1463.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,148.96,percent of total billed charges,38% of total billed charges,2.88,31.95,,31.36,percent of total billed charges,31.95% of total billed charges,4040.94,5692,
NEEDLE 25GX1'''' NON-SAFETY,4201214,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,6.08,percent of total billed charges,38% of total billed charges,5.6,40,,50.88,percent of total billed charges,40% of total billed charges,4041.94,5693,
BLOOD PRESSURE CUFF W/BULB DISP CHILD,4201218,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,35.528,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,35.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,15.2,percent of total billed charges,38% of total billed charges,12,40,,44.48,percent of total billed charges,40% of total billed charges,4042.94,5694,
HISTOFREEZE,4201223,CDM,270,RC,,,OUTPATIENT,,,346,207.6,,294.1,85,,235.28,Percent of total billed charges,85% of total billed charges,173,50,,138.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,173,50,,138.4,percent of total billed charges,50% of total billed charges,110.55,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,110.55,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.48,38,,775.2,percent of total billed charges,38% of total billed charges,138.4,40,,11.52,percent of total billed charges,40% of total billed charges,4043.94,5695,
INSUFFLATION NEEDLE 120MM,4201225,CDM,270,RC,,,OUTPATIENT,,,59.17,35.502,,50.29,85,,40.232,Percent of total billed charges,85% of total billed charges,29.59,50,,23.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.59,50,,23.672,percent of total billed charges,50% of total billed charges,18.9,31.95,,66.2,percent of total billed charges,31.95% of total billed charges,18.9,31.95,,66.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.48,38,,592.8,percent of total billed charges,38% of total billed charges,23.67,40,,82.88,percent of total billed charges,40% of total billed charges,4044.94,5696,
STAT-SITE HGB TEST CARDS,4201227,CDM,270,RC,,,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,84,percent of total billed charges,50% of total billed charges,67.1,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,67.1,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.8,38,,1468.32,percent of total billed charges,38% of total billed charges,84,40,,88.32,percent of total billed charges,40% of total billed charges,4045.94,5697,
BULB FOR LARYNGOSCOPE 04800-U,4201228,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,165.68,percent of total billed charges,38% of total billed charges,6.8,40,,73.6,percent of total billed charges,40% of total billed charges,4046.94,5698,
LABEL DOCTOR YELLOW SOLID SPOON,4201229,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,77.704,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,77.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,165.68,percent of total billed charges,38% of total billed charges,15.2,40,,97.28,percent of total billed charges,40% of total billed charges,4047.94,5699,
HEMOGLOBIN CONTROL (LOW),4201231,CDM,270,RC,,,OUTPATIENT,,,131,78.6,,111.35,85,,89.08,Percent of total billed charges,85% of total billed charges,65.5,50,,52.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,65.5,50,,52.4,percent of total billed charges,50% of total billed charges,41.85,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,41.85,31.95,,12.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.78,38,,91.2,percent of total billed charges,38% of total billed charges,52.4,40,,5.112,percent of total billed charges,40% of total billed charges,4048.94,5700,
CABLE SENSOR PASSPORT 2 SYTLE,4201235,CDM,270,RC,,,OUTPATIENT,,,264,158.4,,224.4,85,,179.52,Percent of total billed charges,85% of total billed charges,132,50,,105.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,132,50,,105.6,percent of total billed charges,50% of total billed charges,84.35,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,84.35,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,100.32,38,,972.8,percent of total billed charges,38% of total billed charges,105.6,40,,108.8,percent of total billed charges,40% of total billed charges,4049.94,5701,
EAR TUBE,4201237,CDM,270,RC,,,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34,50,,27.2,percent of total billed charges,50% of total billed charges,21.73,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,21.73,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.84,38,,42.56,percent of total billed charges,38% of total billed charges,27.2,40,,108.8,percent of total billed charges,40% of total billed charges,4050.94,5702,
THERMOMETER SURETEMP WELCH,4201241,CDM,270,RC,,,OUTPATIENT,,,278,166.8,,236.3,85,,189.04,Percent of total billed charges,85% of total billed charges,139,50,,111.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,139,50,,111.2,percent of total billed charges,50% of total billed charges,88.82,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,88.82,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,105.64,38,,39.52,percent of total billed charges,38% of total billed charges,111.2,40,,30.08,percent of total billed charges,40% of total billed charges,4051.94,5703,
BABY DIAPER SZ 5,4201242,CDM,270,RC,T4529,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,7.38,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,1540.95,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,39.52,percent of total billed charges,38% of total billed charges,6.71,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4052.94,5704,
SIPPY CUP,4201243,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,39.52,percent of total billed charges,38% of total billed charges,2.8,40,,3.064,percent of total billed charges,40% of total billed charges,4053.94,5705,
NEEDLE SPINAL 25GX3.5'''',4201244,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,118.256,percent of total billed charges,38% of total billed charges,3.2,40,,3.064,percent of total billed charges,40% of total billed charges,4054.94,5706,
DEFIBRILLATOR PAD PEDIATRIC (M3504A),4201246,CDM,270,RC,,,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29,50,,23.2,percent of total billed charges,50% of total billed charges,18.53,31.95,,48.056,percent of total billed charges,31.95% of total billed charges,18.53,31.95,,48.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.04,38,,182.4,percent of total billed charges,38% of total billed charges,23.2,40,,60.16,percent of total billed charges,40% of total billed charges,4055.94,5707,
BOVIE 6.5'''' FINE PT EXTENTION,4201247,CDM,270,RC,,,OUTPATIENT,,,52,31.2,,44.2,85,,35.36,Percent of total billed charges,85% of total billed charges,26,50,,20.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26,50,,20.8,percent of total billed charges,50% of total billed charges,16.61,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,16.61,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.76,38,,212.8,percent of total billed charges,38% of total billed charges,20.8,40,,36.8,percent of total billed charges,40% of total billed charges,4056.94,5708,
BABY DIAPER SZ 6,4201248,CDM,270,RC,,,OUTPATIENT,,,9.1,5.46,,7.74,85,,6.192,Percent of total billed charges,85% of total billed charges,4.55,50,,3.64,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.55,50,,3.64,percent of total billed charges,50% of total billed charges,2.91,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,2.91,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.46,38,,304,percent of total billed charges,38% of total billed charges,3.64,40,,16,percent of total billed charges,40% of total billed charges,4057.94,5709,
SPINAL NEEDLE 20GX6,4201249,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,72.96,percent of total billed charges,38% of total billed charges,4.8,40,,3.024,percent of total billed charges,40% of total billed charges,4058.94,5710,
FMC SPINAL NEEDLE 20GX6,4201249,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,38,percent of total billed charges,38% of total billed charges,4.8,40,,76.68,percent of total billed charges,40% of total billed charges,4059.94,5711,
LABEL CHART ''''F'''',4201250,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,84.36,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,661.2,percent of total billed charges,38% of total billed charges,17.6,40,,76.68,percent of total billed charges,40% of total billed charges,4060.94,5712,
LANCET 1.8MM 23G GRAY,4201251,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,661.2,percent of total billed charges,38% of total billed charges,17.2,40,,5.112,percent of total billed charges,40% of total billed charges,4061.94,5713,
NEEDLE 18GX1'''' NON-SAFETY,4201254,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,178.56,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,83.6,percent of total billed charges,38% of total billed charges,6,40,,162.304,percent of total billed charges,40% of total billed charges,4062.94,5714,
B/P CUFF REUSE SMALL CHILD,4201255,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,265.736,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,83.6,percent of total billed charges,38% of total billed charges,15.2,40,,241.544,percent of total billed charges,40% of total billed charges,4063.94,5715,
HANDLE SURGICAL CLIPPER,4201257,CDM,270,RC,,,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57.5,50,,46,percent of total billed charges,50% of total billed charges,36.74,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.7,38,,83.6,percent of total billed charges,38% of total billed charges,46,40,,5.112,percent of total billed charges,40% of total billed charges,4064.94,5716,
SACCAHRIN SOLUTION FIT TEST,4201258,CDM,270,RC,,,OUTPATIENT,,,104,62.4,,88.4,85,,70.72,Percent of total billed charges,85% of total billed charges,52,50,,41.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52,50,,41.6,percent of total billed charges,50% of total billed charges,33.23,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,33.23,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.52,38,,1687.2,percent of total billed charges,38% of total billed charges,41.6,40,,5.112,percent of total billed charges,40% of total billed charges,4065.94,5717,
DECLOGGER BROWN FOR ''''G'''' TUBE,4201266,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,661.2,percent of total billed charges,38% of total billed charges,8.8,40,,2.416,percent of total billed charges,40% of total billed charges,4066.94,5718,
MESH ULTRAPRO LARGE PLUG,4201273,CDM,270,RC,,,OUTPATIENT,,,1010,606,,858.5,85,,686.8,Percent of total billed charges,85% of total billed charges,505,50,,404,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,505,50,,404,percent of total billed charges,50% of total billed charges,322.7,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,322.7,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,383.8,38,,661.2,percent of total billed charges,38% of total billed charges,404,40,,2.416,percent of total billed charges,40% of total billed charges,4067.94,5719,
EXCHANGER KIMVENT 1000 TRACH HEAT AND EXCHANG,4201275,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,139.192,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,224.96,percent of total billed charges,38% of total billed charges,1.6,40,,126.52,percent of total billed charges,40% of total billed charges,4068.94,5720,
TUMBLER GRADUATED 8OZ,4201276,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,2.416,percent of total billed charges,40% of total billed charges,4069.94,5721,
GUAGE DISPOSABLE SPHYGMOMMANOMETER,4201278,CDM,270,RC,,,OUTPATIENT,,,23,13.8,,19.55,85,,15.64,Percent of total billed charges,85% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,7.35,31.95,,139.192,percent of total billed charges,31.95% of total billed charges,7.35,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.74,38,,775.2,percent of total billed charges,38% of total billed charges,9.2,40,,126.52,percent of total billed charges,40% of total billed charges,4070.94,5722,
DEODORANT ANTIPERSPIRANT,4201281,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,23.904,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,18.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,592.8,percent of total billed charges,38% of total billed charges,5,40,,21.728,percent of total billed charges,40% of total billed charges,4071.94,5723,
POLYGRAB TRIPOD,4201286,CDM,270,RC,,,OUTPATIENT,,,189,113.4,,160.65,85,,128.52,Percent of total billed charges,85% of total billed charges,94.5,50,,75.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,94.5,50,,75.6,percent of total billed charges,50% of total billed charges,60.39,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,60.39,31.95,,18.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.82,38,,1231.2,percent of total billed charges,38% of total billed charges,75.6,40,,3.064,percent of total billed charges,40% of total billed charges,4072.94,5724,
BREAST ACHIEVE NEEDLE BIOPSY GUN 14GX11CM,4201289,CDM,270,RC,,,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,19.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.3,38,,115.52,percent of total billed charges,38% of total billed charges,34,40,,2.416,percent of total billed charges,40% of total billed charges,4073.94,5725,
BOVIE TIP 6.5 TEFLON,4201291,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,2.528,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,2.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,661.2,percent of total billed charges,38% of total billed charges,6.4,40,,2.304,percent of total billed charges,40% of total billed charges,4074.94,5726,
PROCEDURAL TRAY UROLOGIST,4201292,CDM,270,RC,,,OUTPATIENT,,,895,537,,760.75,85,,608.6,Percent of total billed charges,85% of total billed charges,447.5,50,,358,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,447.5,50,,358,percent of total billed charges,50% of total billed charges,285.95,31.95,,56.24,percent of total billed charges,31.95% of total billed charges,285.95,31.95,,2.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,340.1,38,,83.6,percent of total billed charges,38% of total billed charges,358,40,,51.12,percent of total billed charges,40% of total billed charges,4075.94,5727,
NEEDLE 17GX10CM HEART SHAPE BREAST BIOPSY,4201294,CDM,270,RC,,,OUTPATIENT,,,356,213.6,,302.6,85,,242.08,Percent of total billed charges,85% of total billed charges,178,50,,142.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,178,50,,142.4,percent of total billed charges,50% of total billed charges,113.74,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,113.74,31.95,,2.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.28,38,,83.6,percent of total billed charges,38% of total billed charges,142.4,40,,2.416,percent of total billed charges,40% of total billed charges,4076.94,5728,
FMC NDL 17GX10CM VENUS SHAPE,4201294,CDM,270,RC,,,OUTPATIENT,,,356,213.6,,302.6,85,,242.08,Percent of total billed charges,85% of total billed charges,178,50,,142.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,178,50,,142.4,percent of total billed charges,50% of total billed charges,113.74,31.95,,89.984,percent of total billed charges,31.95% of total billed charges,113.74,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.28,38,,83.6,percent of total billed charges,38% of total billed charges,142.4,40,,81.792,percent of total billed charges,40% of total billed charges,4077.94,5729,
NEEDLE 17GX10CM VENUS SHAPE BREAST BIOPSY,4201295,CDM,270,RC,,,OUTPATIENT,,,356,213.6,,302.6,85,,242.08,Percent of total billed charges,85% of total billed charges,178,50,,142.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,178,50,,142.4,percent of total billed charges,50% of total billed charges,113.74,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,113.74,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.28,38,,1687.2,percent of total billed charges,38% of total billed charges,142.4,40,,2.416,percent of total billed charges,40% of total billed charges,4078.94,5730,
FMC NDL 17GX10CM HEART SHAPE,4201295,CDM,270,RC,,,OUTPATIENT,,,356,213.6,,302.6,85,,242.08,Percent of total billed charges,85% of total billed charges,178,50,,142.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,178,50,,142.4,percent of total billed charges,50% of total billed charges,113.74,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,113.74,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.28,38,,661.2,percent of total billed charges,38% of total billed charges,142.4,40,,44.8,percent of total billed charges,40% of total billed charges,4079.94,5731,
FILIFORM STRAIGHT TIP 3FR,4201296,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,661.2,percent of total billed charges,38% of total billed charges,19.2,40,,38.4,percent of total billed charges,40% of total billed charges,4080.94,5732,
FILIFORM STRAIGHT TIP 4FR,4201297,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,83.6,percent of total billed charges,38% of total billed charges,19.2,40,,38.4,percent of total billed charges,40% of total billed charges,4081.94,5733,
FILIFORM STRAIGHT 5FR,4201298,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,83.6,percent of total billed charges,38% of total billed charges,19.2,40,,41.6,percent of total billed charges,40% of total billed charges,4082.94,5734,
BED PAN,4201300,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,661.2,percent of total billed charges,38% of total billed charges,2,40,,64,percent of total billed charges,40% of total billed charges,4083.94,5735,
BOVIE TIP 2.5'''' TEFLON,4201301,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,120.688,percent of total billed charges,38% of total billed charges,6.4,40,,57.6,percent of total billed charges,40% of total billed charges,4084.94,5736,
FILIFORM SPIRAL TIP 3FR,4201302,CDM,270,RC,,,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,17.89,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,17.89,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.28,38,,120.08,percent of total billed charges,38% of total billed charges,22.4,40,,62.4,percent of total billed charges,40% of total billed charges,4085.94,5737,
PHILLIPS CATH FOLLOWER 8FR,4201303,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,32.464,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,32.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,446.88,percent of total billed charges,38% of total billed charges,31.2,40,,40.64,percent of total billed charges,40% of total billed charges,4086.94,5738,
PHILLIPS CATH FOLLOWER 10FR,4201304,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,668.8,percent of total billed charges,38% of total billed charges,31.2,40,,17.6,percent of total billed charges,40% of total billed charges,4087.94,5739,
PHILLIPS CATH FOLLOWER 12FR,4201305,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,62.624,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,62.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,592.8,percent of total billed charges,38% of total billed charges,31.2,40,,78.4,percent of total billed charges,40% of total billed charges,4088.94,5740,
PHILLIPS CATH FOLLOWER 14FR,4201306,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,9.12,percent of total billed charges,38% of total billed charges,31.2,40,,54.4,percent of total billed charges,40% of total billed charges,4089.94,5741,
BLOOD COLLECTION SET 21GX3/4 (BUTTERFLY),4201311,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.76,35.15,,14.056,percent of total billed charges,35.15% of total billed charges,1543.19,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,471.808,percent of total billed charges,38% of total billed charges,1.6,31.95,,17.6,percent of total billed charges,31.95% of total billed charges,4090.94,5742,
SYRINGE 20CC LUER-LOK,4201313,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,152,percent of total billed charges,38% of total billed charges,0.4,40,,17.6,percent of total billed charges,40% of total billed charges,4091.94,5743,
PHILLIPS CATH FOLLOWER 18FR,4201316,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,107.92,percent of total billed charges,38% of total billed charges,31.2,40,,28.8,percent of total billed charges,40% of total billed charges,4092.94,5744,
PHILLIPS CATH FOLLOWER 20FR,4201317,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,1231.2,percent of total billed charges,38% of total billed charges,31.2,40,,15.36,percent of total billed charges,40% of total billed charges,4093.94,5745,
PHILLIPS CATH FOLLOWER 22FR,4201318,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,37.96,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,1.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,592.8,percent of total billed charges,38% of total billed charges,31.2,40,,34.504,percent of total billed charges,40% of total billed charges,4094.94,5746,
PHILLIPS CATH FOLLOWER 24FR,4201319,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,115.52,percent of total billed charges,38% of total billed charges,31.2,40,,2.56,percent of total billed charges,40% of total billed charges,4095.94,5747,
PHILLIPS CATH FOLLOWER 26FR,4201320,CDM,270,RC,,,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,39,50,,31.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,39,50,,31.2,percent of total billed charges,50% of total billed charges,24.92,31.95,,2.816,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.64,38,,107.92,percent of total billed charges,38% of total billed charges,31.2,40,,2.56,percent of total billed charges,40% of total billed charges,4096.94,5748,
PHILLIPS BOUGIE FOLLOWER 8FR,4201321,CDM,270,RC,,,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,20.13,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,20.13,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,120.688,percent of total billed charges,38% of total billed charges,25.2,40,,57.6,percent of total billed charges,40% of total billed charges,4097.94,5749,
PHILLIPS BOUGIE FOLLOWER 10FR,4201322,CDM,270,RC,,,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,20.13,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,20.13,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,547.2,percent of total billed charges,38% of total billed charges,25.2,40,,73.6,percent of total billed charges,40% of total billed charges,4098.94,5750,
PHILLIPS BOUGIE FOLLOWER 20FR,4201324,CDM,270,RC,,,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,20.13,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,20.13,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,501.6,percent of total billed charges,38% of total billed charges,25.2,40,,73.6,percent of total billed charges,40% of total billed charges,4099.94,5751,
IODOFORM PACKING STRIP 2'''',4201326,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,1231.2,percent of total billed charges,38% of total billed charges,7.2,40,,27.2,percent of total billed charges,40% of total billed charges,4100.94,5752,
ULTRASOUND GEL 20G PACKET STERILW,4201329,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,49.584,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,49.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,592.8,percent of total billed charges,38% of total billed charges,2,40,,62.08,percent of total billed charges,40% of total billed charges,4101.94,5753,
FMC ULTRASOUND GEL 20G,4201329,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,120.08,percent of total billed charges,38% of total billed charges,2,40,,35.2,percent of total billed charges,40% of total billed charges,4102.94,5754,
AIRWAY BERMAN 50MM,4201330,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,114.608,percent of total billed charges,38% of total billed charges,0.4,40,,54.4,percent of total billed charges,40% of total billed charges,4103.94,5755,
INSUFFLATION NEEDLE 150MM,4201342,CDM,270,RC,,,OUTPATIENT,,,60.83,36.498,,51.71,85,,41.368,Percent of total billed charges,85% of total billed charges,30.42,50,,24.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.42,50,,24.336,percent of total billed charges,50% of total billed charges,19.44,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,19.44,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.12,38,,13.984,percent of total billed charges,38% of total billed charges,24.33,40,,57.6,percent of total billed charges,40% of total billed charges,4104.94,5756,
COLOSTOMY IRRIGATOR KIT,4201346,CDM,270,RC,,,OUTPATIENT,,,84,50.4,,71.4,85,,57.12,Percent of total billed charges,85% of total billed charges,42,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42,50,,33.6,percent of total billed charges,50% of total billed charges,26.84,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,26.84,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.92,38,,152,percent of total billed charges,38% of total billed charges,33.6,40,,57.6,percent of total billed charges,40% of total billed charges,4105.94,5757,
OPSITE DRESSING 4X5.5'''',4201348,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,53.424,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,53.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,592.8,percent of total billed charges,38% of total billed charges,5.6,40,,66.88,percent of total billed charges,40% of total billed charges,4106.94,5758,
GASTRIC LAVAGE CLOSED,4201350,CDM,270,RC,,,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,59,50,,47.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,59,50,,47.2,percent of total billed charges,50% of total billed charges,37.7,31.95,,22.24,percent of total billed charges,31.95% of total billed charges,37.7,31.95,,22.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.84,38,,122.816,percent of total billed charges,38% of total billed charges,47.2,40,,27.84,percent of total billed charges,40% of total billed charges,4107.94,5759,
CERVICAL COLLAR FOAM SMALL,4201354,CDM,270,RC,L0120,HCPCS,OUTPATIENT,,,22.6,13.56,,19.21,85,,15.368,Percent of total billed charges,85% of total billed charges,11.3,50,,9.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.3,50,,9.04,percent of total billed charges,50% of total billed charges,7.94,35.15,,90.736,percent of total billed charges,35.15% of total billed charges,13,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,29.2,100,,,fee schedule,100% of CMS custom fee schedule,8.59,38,,161.12,percent of total billed charges,38% of total billed charges,7.22,31.95,,113.6,percent of total billed charges,31.95% of total billed charges,4108.94,5760,
BLUNT CANNULA,4201363,CDM,270,RC,,,OUTPATIENT,,,4.75,2.85,,4.04,85,,3.232,Percent of total billed charges,85% of total billed charges,2.38,50,,1.904,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.38,50,,1.904,percent of total billed charges,50% of total billed charges,1.52,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,1.52,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.81,38,,161.12,percent of total billed charges,38% of total billed charges,1.9,40,,9.6,percent of total billed charges,40% of total billed charges,4109.94,5761,
CERVICAL COLLAR ADULT UNIVERSAL,4201365,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,32.832,percent of total billed charges,38% of total billed charges,6.4,40,,9.6,percent of total billed charges,40% of total billed charges,4110.94,5762,
COTTON BALL NS 100/BG,4201366,CDM,270,RC,L0120,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,4.22,35.15,,8.44,percent of total billed charges,35.15% of total billed charges,127.8,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,29.2,100,,,fee schedule,100% of CMS custom fee schedule,4.56,38,,1094.4,percent of total billed charges,38% of total billed charges,3.83,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,4111.94,5763,
PRECISE DISPOSABLE STAPLER 15 STAPLES,4201370,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,331.36,percent of total billed charges,38% of total billed charges,11.6,40,,20.8,percent of total billed charges,40% of total billed charges,4112.94,5764,
COLOSTOMY DRAIN BAG 2.75'''',4201371,CDM,270,RC,A5063,HCPCS,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.57,35.15,,6.392,percent of total billed charges,35.15% of total billed charges,127.8,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,3.69,100,,,fee schedule,100% of CMS custom fee schedule,4.94,38,,956.08,percent of total billed charges,38% of total billed charges,4.15,31.95,,8,percent of total billed charges,31.95% of total billed charges,4113.94,5765,
CONNECTOR 6-IN-1 (BUSSE),4201372,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,118.256,percent of total billed charges,38% of total billed charges,3.2,40,,6.72,percent of total billed charges,40% of total billed charges,4114.94,5766,
B/P CUFF ADULT QUICK CONNECT,4201373,CDM,270,RC,,,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,13.1,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,13.1,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.58,38,,118.256,percent of total billed charges,38% of total billed charges,16.4,40,,1.92,percent of total billed charges,40% of total billed charges,4115.94,5767,
ESOPHAGEAL STETHOSCOPE W/TEMP SENSOR,4201374,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,22.12,13.272,,18.8,85,,15.04,Percent of total billed charges,85% of total billed charges,11.06,50,,8.848,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.06,50,,8.848,percent of total billed charges,50% of total billed charges,7.78,35.15,,27.352,percent of total billed charges,35.15% of total billed charges,127.8,31.95,,27.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.41,38,,118.256,percent of total billed charges,38% of total billed charges,7.07,31.95,,34.24,percent of total billed charges,31.95% of total billed charges,4116.94,5768,
CHANNEL CLEANING BURSH,4201381,CDM,270,RC,,,OUTPATIENT,,,28.7,17.22,,24.4,85,,19.52,Percent of total billed charges,85% of total billed charges,14.35,50,,11.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.35,50,,11.48,percent of total billed charges,50% of total billed charges,9.17,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,9.17,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.91,38,,118.256,percent of total billed charges,38% of total billed charges,11.48,40,,17.6,percent of total billed charges,40% of total billed charges,4117.94,5769,
WOUND CLOSURE TRAY,4201385,CDM,270,RC,A4550,HCPCS,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.62,35.15,,63.904,percent of total billed charges,35.15% of total billed charges,128.44,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,118.256,percent of total billed charges,38% of total billed charges,5.11,31.95,,80,percent of total billed charges,31.95% of total billed charges,4118.94,5770,
EAR WICK PKG,4201386,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,592.8,percent of total billed charges,38% of total billed charges,5.6,40,,80,percent of total billed charges,40% of total billed charges,4119.94,5771,
DEFIBRILLATOR PADS,4201387,CDM,270,RC,,,OUTPATIENT,,,67,40.2,,56.95,85,,45.56,Percent of total billed charges,85% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,21.41,31.95,,31.184,percent of total billed charges,31.95% of total billed charges,21.41,31.95,,31.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.46,38,,820.8,percent of total billed charges,38% of total billed charges,26.8,40,,39.04,percent of total billed charges,40% of total billed charges,4120.94,5772,
TRAY LEGAL STACKING,4201389,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,5.95,3.57,,5.06,85,,4.048,Percent of total billed charges,85% of total billed charges,2.98,50,,2.384,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.98,50,,2.384,percent of total billed charges,50% of total billed charges,2.09,35.15,,31.184,percent of total billed charges,35.15% of total billed charges,129.08,31.95,,31.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.26,38,,410.4,percent of total billed charges,38% of total billed charges,1.9,31.95,,39.04,percent of total billed charges,31.95% of total billed charges,4121.94,5773,
BABY DIAPER SZ 4 LARGE 24/PK,4201406,CDM,270,RC,T4533,HCPCS,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.92,35.15,,19.68,percent of total billed charges,35.15% of total billed charges,129.08,31.95,,19.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,304,percent of total billed charges,38% of total billed charges,4.47,31.95,,24.64,percent of total billed charges,31.95% of total billed charges,4122.94,5774,
SLIPPER LARGE DISPOSABLE,4201413,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,28.624,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,28.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,93.632,percent of total billed charges,38% of total billed charges,1.6,40,,35.84,percent of total billed charges,40% of total billed charges,4123.94,5775,
PORTA-WARM MATTRESS,4201425,CDM,270,RC,,,OUTPATIENT,,,76,45.6,,64.6,85,,51.68,Percent of total billed charges,85% of total billed charges,38,50,,30.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38,50,,30.4,percent of total billed charges,50% of total billed charges,24.28,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,24.28,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.88,38,,103.36,percent of total billed charges,38% of total billed charges,30.4,40,,53.76,percent of total billed charges,40% of total billed charges,4124.94,5776,
ENDO CLIP DISP (M-L),4201429,CDM,270,RC,,,OUTPATIENT,,,67.4,40.44,,57.29,85,,45.832,Percent of total billed charges,85% of total billed charges,33.7,50,,26.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.7,50,,26.96,percent of total billed charges,50% of total billed charges,21.53,31.95,,75.4,percent of total billed charges,31.95% of total billed charges,21.53,31.95,,75.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.61,38,,1118.72,percent of total billed charges,38% of total billed charges,26.96,40,,94.4,percent of total billed charges,40% of total billed charges,4125.94,5777,
DRESSING ISLAND ADHESIVE 4X5''''  (COLVIN),4201435,CDM,270,RC,,,OUTPATIENT,,,15.68,9.408,,13.33,85,,10.664,Percent of total billed charges,85% of total billed charges,7.84,50,,6.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.84,50,,6.272,percent of total billed charges,50% of total billed charges,5.01,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,5.01,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.96,38,,114,percent of total billed charges,38% of total billed charges,6.27,40,,48,percent of total billed charges,40% of total billed charges,4126.94,5778,
ENDO SHEARS 5MM,4201440,CDM,270,RC,,,OUTPATIENT,,,229.18,137.508,,194.8,85,,155.84,Percent of total billed charges,85% of total billed charges,114.59,50,,91.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,114.59,50,,91.672,percent of total billed charges,50% of total billed charges,73.22,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,73.22,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,87.09,38,,97.28,percent of total billed charges,38% of total billed charges,91.67,40,,4.8,percent of total billed charges,40% of total billed charges,4127.94,5779,
CHLORAPREP SURGICAL SKIN PREP 26ML (SURGERY),4201442,CDM,270,RC,A4358,HCPCS,OUTPATIENT,,,12.96,7.776,,11.02,85,,8.816,Percent of total billed charges,85% of total billed charges,6.48,50,,5.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.48,50,,5.184,percent of total billed charges,50% of total billed charges,4.56,35.15,,50.608,percent of total billed charges,35.15% of total billed charges,129.4,31.95,,50.608,percent of total billed charges,31.95% of total billed charges,9.05,100,,,fee schedule,100% of CMS custom fee schedule,4.92,38,,124.64,percent of total billed charges,38% of total billed charges,4.14,31.95,,63.36,percent of total billed charges,31.95% of total billed charges,4128.94,5780,
FMC OR TOWELS STERILE,4201449,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,76,percent of total billed charges,38% of total billed charges,5.4,40,,16,percent of total billed charges,40% of total billed charges,4129.94,5781,
ENDO CLINCH,4201454,CDM,270,RC,,,OUTPATIENT,,,171.1,102.66,,145.44,85,,116.352,Percent of total billed charges,85% of total billed charges,85.55,50,,68.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85.55,50,,68.44,percent of total billed charges,50% of total billed charges,54.67,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,54.67,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,65.02,38,,121.6,percent of total billed charges,38% of total billed charges,68.44,40,,25.6,percent of total billed charges,40% of total billed charges,4130.94,5782,
ER LACERATION TRAY,4201456,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,8.44,35.15,,25.56,percent of total billed charges,35.15% of total billed charges,13.32,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,120.08,percent of total billed charges,38% of total billed charges,7.67,31.95,,32,percent of total billed charges,31.95% of total billed charges,4131.94,5783,
ELASTOPLAST ADH. BANDAGE 3',4201470,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,106.4,percent of total billed charges,38% of total billed charges,7.2,40,,48.96,percent of total billed charges,40% of total billed charges,4132.94,5784,
ELASTOPLAST ADH. BANDAGE 2',4201471,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.98,35.15,,55.208,percent of total billed charges,35.15% of total billed charges,13.32,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,3.8,percent of total billed charges,38% of total billed charges,5.43,31.95,,69.12,percent of total billed charges,31.95% of total billed charges,4133.94,5785,
ELBOW PROTECTOR,4201474,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,820.8,percent of total billed charges,38% of total billed charges,7.2,40,,31.36,percent of total billed charges,40% of total billed charges,4134.94,5786,
VERSAPORT 5MM,4201477,CDM,270,RC,,,OUTPATIENT,,,46.57,27.942,,39.58,85,,31.664,Percent of total billed charges,85% of total billed charges,23.29,50,,18.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.29,50,,18.632,percent of total billed charges,50% of total billed charges,14.88,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,14.88,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.7,38,,775.2,percent of total billed charges,38% of total billed charges,18.63,40,,47.68,percent of total billed charges,40% of total billed charges,4135.94,5787,
VERSAPORT 11MM,4201478,CDM,270,RC,,,OUTPATIENT,,,55.43,33.258,,47.12,85,,37.696,Percent of total billed charges,85% of total billed charges,27.72,50,,22.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.72,50,,22.176,percent of total billed charges,50% of total billed charges,17.71,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,17.71,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.06,38,,176.32,percent of total billed charges,38% of total billed charges,22.17,40,,81.6,percent of total billed charges,40% of total billed charges,4136.94,5788,
ENDOBITE BLOCK,4201481,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,176.32,percent of total billed charges,38% of total billed charges,5.2,40,,105.28,percent of total billed charges,40% of total billed charges,4137.94,5789,
3000CC SODIUM CLORIDE IRRI PIC CONTAINER,4201482,CDM,270,RC,,,OUTPATIENT,,,25.84,15.504,,21.96,85,,17.568,Percent of total billed charges,85% of total billed charges,12.92,50,,10.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.92,50,,10.336,percent of total billed charges,50% of total billed charges,8.26,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,8.26,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.82,38,,1064,percent of total billed charges,38% of total billed charges,10.34,40,,20.8,percent of total billed charges,40% of total billed charges,4138.94,5790,
ET TUBE 10.0,4201493,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,501.6,percent of total billed charges,38% of total billed charges,5.4,40,,20.8,percent of total billed charges,40% of total billed charges,4139.94,5791,
PAPER COPY WHITE 8.5''''X11'''',4201498,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,273.6,percent of total billed charges,38% of total billed charges,0.8,40,,54.4,percent of total billed charges,40% of total billed charges,4140.94,5792,
FLEXISENSOR CABLE ADULT,4201504,CDM,270,RC,,,OUTPATIENT,,,293,175.8,,249.05,85,,199.24,Percent of total billed charges,85% of total billed charges,146.5,50,,117.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,146.5,50,,117.2,percent of total billed charges,50% of total billed charges,93.61,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,93.61,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,111.34,38,,592.8,percent of total billed charges,38% of total billed charges,117.2,40,,36.8,percent of total billed charges,40% of total billed charges,4141.94,5793,
FLEXISENSOR PEDIATRIC,4201505,CDM,270,RC,,,OUTPATIENT,,,232,139.2,,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,92.8,percent of total billed charges,50% of total billed charges,74.12,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,74.12,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.16,38,,9.12,percent of total billed charges,38% of total billed charges,92.8,40,,14.4,percent of total billed charges,40% of total billed charges,4142.94,5794,
FLEXISENSOR INFANT,4201506,CDM,270,RC,,,OUTPATIENT,,,232,139.2,,197.2,85,,157.76,Percent of total billed charges,85% of total billed charges,116,50,,92.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,116,50,,92.8,percent of total billed charges,50% of total billed charges,74.12,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,74.12,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.16,38,,9.12,percent of total billed charges,38% of total billed charges,92.8,40,,40,percent of total billed charges,40% of total billed charges,4143.94,5795,
SHARPS CONTAINER 3GL.,4201512,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,9.12,percent of total billed charges,38% of total billed charges,7.6,40,,14.4,percent of total billed charges,40% of total billed charges,4144.94,5796,
SHARPS CONTAINER 5.4QT,4201513,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,9.12,percent of total billed charges,38% of total billed charges,5.2,40,,44.8,percent of total billed charges,40% of total billed charges,4145.94,5797,
ELECTRODE EXT. BLADE,4201514,CDM,270,RC,,,OUTPATIENT,,,13.57,8.142,,11.53,85,,9.224,Percent of total billed charges,85% of total billed charges,6.79,50,,5.432,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.79,50,,5.432,percent of total billed charges,50% of total billed charges,4.34,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,4.34,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.16,38,,139.84,percent of total billed charges,38% of total billed charges,5.43,40,,16,percent of total billed charges,40% of total billed charges,4146.94,5798,
SPECIMEN TUMBLERS GRADUATED,4201522,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,273.6,percent of total billed charges,38% of total billed charges,0.4,40,,64,percent of total billed charges,40% of total billed charges,4147.94,5799,
LOOP OSTOMY BRIDGE,4201524,CDM,270,RC,,,OUTPATIENT,,,13.08,7.848,,11.12,85,,8.896,Percent of total billed charges,85% of total billed charges,6.54,50,,5.232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.54,50,,5.232,percent of total billed charges,50% of total billed charges,4.18,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,4.18,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.97,38,,150.784,percent of total billed charges,38% of total billed charges,5.23,40,,24,percent of total billed charges,40% of total billed charges,4148.94,5800,
GIGLI SAW BLADE,4201526,CDM,270,RC,,,OUTPATIENT,,,64,38.4,,54.4,85,,43.52,Percent of total billed charges,85% of total billed charges,32,50,,25.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32,50,,25.6,percent of total billed charges,50% of total billed charges,20.45,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,20.45,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.32,38,,21.888,percent of total billed charges,38% of total billed charges,25.6,40,,128,percent of total billed charges,40% of total billed charges,4149.94,5801,
GELFOAM SPONGE CZ 100,4201534,CDM,270,RC,,,OUTPATIENT,,,133,79.8,,113.05,85,,90.44,Percent of total billed charges,85% of total billed charges,66.5,50,,53.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,66.5,50,,53.2,percent of total billed charges,50% of total billed charges,42.49,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,42.49,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.54,38,,21.888,percent of total billed charges,38% of total billed charges,53.2,40,,56,percent of total billed charges,40% of total billed charges,4150.94,5802,
INJECTION CAP,4201535,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,21.888,percent of total billed charges,38% of total billed charges,5.6,40,,73.6,percent of total billed charges,40% of total billed charges,4151.94,5803,
L HOOK ELECTRODE TIP 36CM STERILE,4201538,CDM,270,RC,,,OUTPATIENT,,,310,186,,263.5,85,,210.8,Percent of total billed charges,85% of total billed charges,155,50,,124,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,155,50,,124,percent of total billed charges,50% of total billed charges,99.05,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,99.05,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.8,38,,115.52,percent of total billed charges,38% of total billed charges,124,40,,28.8,percent of total billed charges,40% of total billed charges,4152.94,5804,
HEEL PROTECTORS PAIR,4201541,CDM,270,RC,E0191,HCPCS,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.57,35.15,,21.728,percent of total billed charges,35.15% of total billed charges,13.32,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,43.776,percent of total billed charges,38% of total billed charges,4.15,31.95,,27.2,percent of total billed charges,31.95% of total billed charges,4153.94,5805,
SKIN MARKER NON STERILE,4201562,CDM,270,RC,A4648,HCPCS,OUTPATIENT,,,4.05,2.43,,3.44,85,,2.752,Percent of total billed charges,85% of total billed charges,2.03,50,,1.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.03,50,,1.624,percent of total billed charges,50% of total billed charges,1.42,35.15,,60.064,percent of total billed charges,35.15% of total billed charges,131.31,31.95,,60.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.54,38,,1231.2,percent of total billed charges,38% of total billed charges,1.29,31.95,,75.2,percent of total billed charges,31.95% of total billed charges,4154.94,5806,
POUCH STERILIZATION 3.5''''X9'''',4201564,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,775.2,percent of total billed charges,38% of total billed charges,15.2,40,,56,percent of total billed charges,40% of total billed charges,4155.94,5807,
LEVINE TUBE 10,4201575,CDM,270,RC,,,OUTPATIENT,,,10.55,6.33,,8.97,85,,7.176,Percent of total billed charges,85% of total billed charges,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.28,50,,4.224,percent of total billed charges,50% of total billed charges,3.37,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,3.37,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.01,38,,592.8,percent of total billed charges,38% of total billed charges,4.22,40,,81.6,percent of total billed charges,40% of total billed charges,4156.94,5808,
LIMB RESTRAINT DISPOSABLE,4201578,CDM,270,RC,E0710,HCPCS,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.68,35.15,,51.12,percent of total billed charges,35.15% of total billed charges,131.63,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,541.12,percent of total billed charges,38% of total billed charges,6.07,31.95,,64,percent of total billed charges,31.95% of total billed charges,4157.94,5809,
MASK CHILDREN,4201579,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,592.8,percent of total billed charges,38% of total billed charges,5.6,40,,73.6,percent of total billed charges,40% of total billed charges,4158.94,5810,
MARKER PERMANENT BLACK,4201588,CDM,270,RC,,,OUTPATIENT,,,24.75,14.85,,21.04,85,,16.832,Percent of total billed charges,85% of total billed charges,12.38,50,,9.904,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.38,50,,9.904,percent of total billed charges,50% of total billed charges,7.91,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,7.91,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.41,38,,820.8,percent of total billed charges,38% of total billed charges,9.9,40,,73.6,percent of total billed charges,40% of total billed charges,4159.94,5811,
PEANUT SPONGE 3/8'''',4201604,CDM,270,RC,,,OUTPATIENT,,,8.68,5.208,,7.38,85,,5.904,Percent of total billed charges,85% of total billed charges,4.34,50,,3.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.34,50,,3.472,percent of total billed charges,50% of total billed charges,2.77,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,2.77,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.3,38,,775.2,percent of total billed charges,38% of total billed charges,3.47,40,,27.2,percent of total billed charges,40% of total billed charges,4160.94,5812,
"ROLLERBALL ELECTRODE, 5MM",4201605,CDM,270,RC,,,OUTPATIENT,,,187,112.2,,158.95,85,,127.16,Percent of total billed charges,85% of total billed charges,93.5,50,,74.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,93.5,50,,74.8,percent of total billed charges,50% of total billed charges,59.75,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,59.75,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.06,38,,2763.968,percent of total billed charges,38% of total billed charges,74.8,40,,35.2,percent of total billed charges,40% of total billed charges,4161.94,5813,
SOAP BODY BAR,4201606,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,1763.2,percent of total billed charges,38% of total billed charges,0.4,40,,54.4,percent of total billed charges,40% of total billed charges,4162.94,5814,
SURGICEL ABORB HEMOSTAT 4X8,4201619,CDM,270,RC,,,OUTPATIENT,,,159.9,95.94,,135.92,85,,108.736,Percent of total billed charges,85% of total billed charges,79.95,50,,63.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79.95,50,,63.96,percent of total billed charges,50% of total billed charges,51.09,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,51.09,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.76,38,,456,percent of total billed charges,38% of total billed charges,63.96,40,,73.6,percent of total billed charges,40% of total billed charges,4163.94,5815,
PREGNANCY (HCG) DIPSTICK RAPID TEST,4201624,CDM,270,RC,,,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,62.5,50,,50,percent of total billed charges,50% of total billed charges,39.94,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.5,38,,456,percent of total billed charges,38% of total billed charges,50,40,,44.8,percent of total billed charges,40% of total billed charges,4164.94,5816,
SPONGE GUAZE 2X2 NONSTERILE BULK PK,4201629,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1010.8,percent of total billed charges,38% of total billed charges,1.6,40,,25.6,percent of total billed charges,40% of total billed charges,4165.94,5817,
HEMOCCULT CARD (BECKMAN COULTER),4201630,CDM,270,RC,,,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,61,50,,48.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,61,50,,48.8,percent of total billed charges,50% of total billed charges,38.98,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,38.98,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.36,38,,475.456,percent of total billed charges,38% of total billed charges,48.8,40,,32,percent of total billed charges,40% of total billed charges,4166.94,5818,
"SPONGES, TONSIL 5/PK",4201631,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,3.16,35.15,,39.104,percent of total billed charges,35.15% of total billed charges,13.42,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,528.96,percent of total billed charges,38% of total billed charges,2.88,31.95,,48.96,percent of total billed charges,31.95% of total billed charges,4167.94,5819,
STERI STRIP 1/2,4201634,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,528.96,percent of total billed charges,38% of total billed charges,2,40,,69.12,percent of total billed charges,40% of total billed charges,4168.94,5820,
"STOP COCK, 4 WAY",4201642,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,114,percent of total billed charges,38% of total billed charges,2,40,,31.36,percent of total billed charges,40% of total billed charges,4169.94,5821,
GLOVE EXAM SMALL VINYL,4201645,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,3.11,1.866,,2.64,85,,2.112,Percent of total billed charges,85% of total billed charges,1.56,50,,1.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.56,50,,1.248,percent of total billed charges,50% of total billed charges,1.09,35.15,,38.088,percent of total billed charges,35.15% of total billed charges,13.42,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.18,38,,775.2,percent of total billed charges,38% of total billed charges,0.99,31.95,,47.68,percent of total billed charges,31.95% of total billed charges,4170.94,5822,
SALEM SUMP TUBE 10,4201646,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,10.75,6.45,,9.14,85,,7.312,Percent of total billed charges,85% of total billed charges,5.38,50,,4.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.38,50,,4.304,percent of total billed charges,50% of total billed charges,3.78,35.15,,65.176,percent of total billed charges,35.15% of total billed charges,13.42,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.09,38,,592.8,percent of total billed charges,38% of total billed charges,3.43,31.95,,81.6,percent of total billed charges,31.95% of total billed charges,4171.94,5823,
CRUTCHES YOUTH,4201656,CDM,270,RC,E0112,HCPCS,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,14.41,35.15,,84.096,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.58,38,,592.8,percent of total billed charges,38% of total billed charges,13.1,31.95,,105.28,percent of total billed charges,31.95% of total billed charges,4172.94,5824,
PEROXIDE HYDROGEN,4201658,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,54.44,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,54.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,1094.4,percent of total billed charges,38% of total billed charges,0.8,40,,68.16,percent of total billed charges,40% of total billed charges,4173.94,5825,
CRUTCHES ADULT,4201661,CDM,270,RC,E0112,HCPCS,OUTPATIENT,,,89,53.4,,75.65,85,,60.52,Percent of total billed charges,85% of total billed charges,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44.5,50,,35.6,percent of total billed charges,50% of total billed charges,31.28,35.15,,63.904,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.82,38,,789.792,percent of total billed charges,38% of total billed charges,28.44,31.95,,80,percent of total billed charges,31.95% of total billed charges,4174.94,5826,
CRUTCHES TALL ADULT,4201662,CDM,270,RC,E0112,HCPCS,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,13.36,35.15,,127.8,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,120.688,percent of total billed charges,38% of total billed charges,12.14,31.95,,160,percent of total billed charges,31.95% of total billed charges,4175.94,5827,
TAPE SILK 2'''',4201664,CDM,270,RC,,,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,13.1,31.95,,306.72,percent of total billed charges,31.95% of total billed charges,13.1,31.95,,306.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.58,38,,1094.4,percent of total billed charges,38% of total billed charges,16.4,40,,384,percent of total billed charges,40% of total billed charges,4176.94,5828,
TROCAR THORACIC CATHETER 24FR,4201671,CDM,270,RC,,,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,11.82,31.95,,63.272,percent of total billed charges,31.95% of total billed charges,11.82,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.06,38,,34.96,percent of total billed charges,38% of total billed charges,14.8,40,,57.512,percent of total billed charges,40% of total billed charges,4177.94,5829,
OBSTETRICAL PACK,4201672,CDM,270,RC,,,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,17,50,,13.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17,50,,13.6,percent of total billed charges,50% of total billed charges,10.86,31.95,,63.272,percent of total billed charges,31.95% of total billed charges,10.86,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.92,38,,1094.4,percent of total billed charges,38% of total billed charges,13.6,40,,57.512,percent of total billed charges,40% of total billed charges,4178.94,5830,
28FR 30CC RIBBED 0166L28,4201679,CDM,270,RC,,,OUTPATIENT,,,27.2,16.32,,23.12,85,,18.496,Percent of total billed charges,85% of total billed charges,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.6,50,,10.88,percent of total billed charges,50% of total billed charges,8.69,31.95,,124.736,percent of total billed charges,31.95% of total billed charges,8.69,31.95,,124.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.34,38,,501.6,percent of total billed charges,38% of total billed charges,10.88,40,,156.16,percent of total billed charges,40% of total billed charges,4179.94,5831,
SYRINGE 10CC ST 301604,4201681,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,130.36,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,130.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,699.2,percent of total billed charges,38% of total billed charges,11.6,40,,163.2,percent of total billed charges,40% of total billed charges,4180.94,5832,
URIMETER,4201687,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,162.304,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,162.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,1094.4,percent of total billed charges,38% of total billed charges,11.2,40,,203.2,percent of total billed charges,40% of total billed charges,4181.94,5833,
CALCULI STRAINER,4201690,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,2.11,35.15,,138.28,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1231.2,percent of total billed charges,38% of total billed charges,1.92,31.95,,173.12,percent of total billed charges,31.95% of total billed charges,4182.94,5834,
STERILE SURGICAL MARKING PEN,4201692,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,592.8,percent of total billed charges,38% of total billed charges,7.6,40,,173.12,percent of total billed charges,40% of total billed charges,4183.94,5835,
FMC STERILE MARKING PEN,4201692,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,326.384,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,326.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,951.52,percent of total billed charges,38% of total billed charges,7.6,40,,408.616,percent of total billed charges,40% of total billed charges,4184.94,5836,
VESSEL LOOP BLUE,4201693,CDM,270,RC,,,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,1277.032,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,1277.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,24.32,percent of total billed charges,38% of total billed charges,9.6,40,,1598.784,percent of total billed charges,40% of total billed charges,4185.94,5837,
VALLEY LAB HAND ROCKER SWITCH,4201695,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,24.32,percent of total billed charges,38% of total billed charges,10.8,40,,120,percent of total billed charges,40% of total billed charges,4186.94,5838,
POWERPORT MRI DEVICE 9.6FR.,4201697,CDM,270,RC,,,OUTPATIENT,,,851.4,510.84,,723.69,85,,578.952,Percent of total billed charges,85% of total billed charges,425.7,50,,340.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,425.7,50,,340.56,percent of total billed charges,50% of total billed charges,272.02,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,272.02,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,323.53,38,,118.256,percent of total billed charges,38% of total billed charges,340.56,40,,173.12,percent of total billed charges,40% of total billed charges,4187.94,5839,
PETROLEUM GAUZE 1X8,4201698,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,26.752,percent of total billed charges,38% of total billed charges,1.2,40,,192,percent of total billed charges,40% of total billed charges,4188.94,5840,
RELOAD 45MM LINEAR CUTTER WHITE,4201699,CDM,270,RC,,,OUTPATIENT,,,404.91,242.946,,344.17,85,,275.336,Percent of total billed charges,85% of total billed charges,202.46,50,,161.968,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,202.46,50,,161.968,percent of total billed charges,50% of total billed charges,129.37,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,129.37,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,153.87,38,,1389.28,percent of total billed charges,38% of total billed charges,161.96,40,,6.4,percent of total billed charges,40% of total billed charges,4189.94,5841,
TAPE SILK 1'''',4201704,CDM,270,RC,,,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.58,38,,617.12,percent of total billed charges,38% of total billed charges,16.4,40,,13.12,percent of total billed charges,40% of total billed charges,4190.94,5842,
LABEL DOCTOR TAN SOLID SPOON,4201707,CDM,270,RC,,,OUTPATIENT,,,33.75,20.25,,28.69,85,,22.952,Percent of total billed charges,85% of total billed charges,16.88,50,,13.504,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.88,50,,13.504,percent of total billed charges,50% of total billed charges,10.78,31.95,,8.624,percent of total billed charges,31.95% of total billed charges,10.78,31.95,,8.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.83,38,,486.4,percent of total billed charges,38% of total billed charges,13.5,40,,10.8,percent of total billed charges,40% of total billed charges,4191.94,5843,
SURGICLIP APPLIER M-11,4201717,CDM,270,RC,,,OUTPATIENT,,,117.93,70.758,,100.24,85,,80.192,Percent of total billed charges,85% of total billed charges,58.97,50,,47.176,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,58.97,50,,47.176,percent of total billed charges,50% of total billed charges,37.68,31.95,,30.144,percent of total billed charges,31.95% of total billed charges,37.68,31.95,,30.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.81,38,,501.6,percent of total billed charges,38% of total billed charges,47.17,40,,37.736,percent of total billed charges,40% of total billed charges,4192.94,5844,
TUBEGUAZE 5/8''''X50YDS WHITE,4201718,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,501.6,percent of total billed charges,38% of total billed charges,0.4,40,,0.32,percent of total billed charges,40% of total billed charges,4193.94,5845,
SKIN STAPLE REMOVER,4201719,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.76,35.15,,1.408,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,501.6,percent of total billed charges,38% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,4194.94,5846,
TOOTHETTES,4201723,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,820.8,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4195.94,5847,
TUBEGAUZE 2'''',4201729,CDM,270,RC,,,OUTPATIENT,,,46.29,27.774,,39.35,85,,31.48,Percent of total billed charges,85% of total billed charges,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,14.79,31.95,,11.832,percent of total billed charges,31.95% of total billed charges,14.79,31.95,,11.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.59,38,,592.8,percent of total billed charges,38% of total billed charges,18.52,40,,14.816,percent of total billed charges,40% of total billed charges,4196.94,5848,
PREMIUM 35W SKIN STAPLER MULTI,4201731,CDM,270,RC,,,OUTPATIENT,,,20.58,12.348,,17.49,85,,13.992,Percent of total billed charges,85% of total billed charges,10.29,50,,8.232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.29,50,,8.232,percent of total billed charges,50% of total billed charges,6.58,31.95,,5.264,percent of total billed charges,31.95% of total billed charges,6.58,31.95,,5.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.82,38,,592.8,percent of total billed charges,38% of total billed charges,8.23,40,,6.584,percent of total billed charges,40% of total billed charges,4197.94,5849,
CATHETER ADAPTER (CHRISTMAS TREE BLUE),4201741,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,1672,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4198.94,5850,
PENROSE DRAIN 1/4'''',4201746,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,617.12,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4199.94,5851,
COLOSTOMY KIT 1.25,4201747,CDM,270,RC,,,OUTPATIENT,,,17.56,10.536,,14.93,85,,11.944,Percent of total billed charges,85% of total billed charges,8.78,50,,7.024,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.78,50,,7.024,percent of total billed charges,50% of total billed charges,5.61,31.95,,4.488,percent of total billed charges,31.95% of total billed charges,5.61,31.95,,4.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.67,38,,486.4,percent of total billed charges,38% of total billed charges,7.02,40,,5.616,percent of total billed charges,40% of total billed charges,4200.94,5852,
"PENROSE DRAIN, 5/8''''",4201750,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,228,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4201.94,5853,
"PENROSE DRAIN, 1''''",4201751,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,820.8,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4202.94,5854,
JACKSON PRATT,4201759,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,60.8,percent of total billed charges,38% of total billed charges,15.2,40,,12.16,percent of total billed charges,40% of total billed charges,4203.94,5855,
STAPLER LINEAR RELOAD 60MM,4201773,CDM,270,RC,,,OUTPATIENT,,,115.2,69.12,,97.92,85,,78.336,Percent of total billed charges,85% of total billed charges,57.6,50,,46.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57.6,50,,46.08,percent of total billed charges,50% of total billed charges,36.81,31.95,,29.448,percent of total billed charges,31.95% of total billed charges,36.81,31.95,,29.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.78,38,,592.8,percent of total billed charges,38% of total billed charges,46.08,40,,36.864,percent of total billed charges,40% of total billed charges,4204.94,5856,
STAPLER LINEAR 60MM,4201774,CDM,270,RC,,,OUTPATIENT,,,345.6,207.36,,293.76,85,,235.008,Percent of total billed charges,85% of total billed charges,172.8,50,,138.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,172.8,50,,138.24,percent of total billed charges,50% of total billed charges,110.42,31.95,,88.336,percent of total billed charges,31.95% of total billed charges,110.42,31.95,,88.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.33,38,,501.6,percent of total billed charges,38% of total billed charges,138.24,40,,110.592,percent of total billed charges,40% of total billed charges,4205.94,5857,
STAPLER LINEAR RELOAD 30MM,4201775,CDM,270,RC,,,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,112.5,50,,90,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,112.5,50,,90,percent of total billed charges,50% of total billed charges,71.89,31.95,,57.512,percent of total billed charges,31.95% of total billed charges,71.89,31.95,,57.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,85.5,38,,1094.4,percent of total billed charges,38% of total billed charges,90,40,,72,percent of total billed charges,40% of total billed charges,4206.94,5858,
PLEUR-EVAC,4201788,CDM,270,RC,,,OUTPATIENT,,,189,113.4,,160.65,85,,128.52,Percent of total billed charges,85% of total billed charges,94.5,50,,75.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,94.5,50,,75.6,percent of total billed charges,50% of total billed charges,60.39,31.95,,48.312,percent of total billed charges,31.95% of total billed charges,60.39,31.95,,48.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,71.82,38,,592.8,percent of total billed charges,38% of total billed charges,75.6,40,,60.48,percent of total billed charges,40% of total billed charges,4207.94,5859,
BABY DIAPER SZ 3 MEDIUM 12/PK,4201789,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,162.64,percent of total billed charges,38% of total billed charges,5.2,40,,4.16,percent of total billed charges,40% of total billed charges,4208.94,5860,
DIAPER REGULAR ADULT BREATHABLE,4201791,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,547.2,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4209.94,5861,
DIAPER LARGE ADULT BREATHABLE,4201792,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,822.32,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4210.94,5862,
PEN PAPERMATE FINE RED,4201794,CDM,270,RC,,,OUTPATIENT,,,28.68,17.208,,24.38,85,,19.504,Percent of total billed charges,85% of total billed charges,14.34,50,,11.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.34,50,,11.472,percent of total billed charges,50% of total billed charges,9.16,31.95,,7.328,percent of total billed charges,31.95% of total billed charges,9.16,31.95,,7.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.9,38,,820.8,percent of total billed charges,38% of total billed charges,11.47,40,,9.176,percent of total billed charges,40% of total billed charges,4211.94,5863,
STENT MARDIS URETERAL 6X26,4201795,CDM,270,RC,,,OUTPATIENT,,,397.53,238.518,,337.9,85,,270.32,Percent of total billed charges,85% of total billed charges,198.77,50,,159.016,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,198.77,50,,159.016,percent of total billed charges,50% of total billed charges,127.01,31.95,,101.608,percent of total billed charges,31.95% of total billed charges,127.01,31.95,,101.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,151.06,38,,228,percent of total billed charges,38% of total billed charges,159.01,40,,127.208,percent of total billed charges,40% of total billed charges,4212.94,5864,
ESOPHOGEAL TUBE FOUR LUMEN MINNESOTA 18FR,4201800,CDM,270,RC,,,OUTPATIENT,,,1400,840,,1190,85,,952,Percent of total billed charges,85% of total billed charges,700,50,,560,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,700,50,,560,percent of total billed charges,50% of total billed charges,447.3,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,532,38,,822.32,percent of total billed charges,38% of total billed charges,560,40,,448,percent of total billed charges,40% of total billed charges,4213.94,5865,
DIAL-A-FLO IV SET,4201801,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,822.32,percent of total billed charges,38% of total billed charges,15.2,40,,12.16,percent of total billed charges,40% of total billed charges,4214.94,5866,
HAND SANITIZER FOAM 7OZ CAN,4201806,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,228,percent of total billed charges,38% of total billed charges,5.6,40,,4.48,percent of total billed charges,40% of total billed charges,4215.94,5867,
"RIB BELT, COMFORT FEMALE",4201851,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,410.4,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,4216.94,5868,
WOUND RETRACTOR LARGE,4201853,CDM,270,RC,,,OUTPATIENT,,,126,75.6,,107.1,85,,85.68,Percent of total billed charges,85% of total billed charges,63,50,,50.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,63,50,,50.4,percent of total billed charges,50% of total billed charges,40.26,31.95,,32.208,percent of total billed charges,31.95% of total billed charges,40.26,31.95,,32.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.88,38,,228,percent of total billed charges,38% of total billed charges,50.4,40,,40.32,percent of total billed charges,40% of total billed charges,4217.94,5869,
STENT URETERAL POLARIS ULTRA 5X18,4201857,CDM,270,RC,,,OUTPATIENT,,,574,344.4,,487.9,85,,390.32,Percent of total billed charges,85% of total billed charges,287,50,,229.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,287,50,,229.6,percent of total billed charges,50% of total billed charges,183.39,31.95,,146.712,percent of total billed charges,31.95% of total billed charges,183.39,31.95,,146.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,218.12,38,,820.8,percent of total billed charges,38% of total billed charges,229.6,40,,183.68,percent of total billed charges,40% of total billed charges,4218.94,5870,
STENT URETERAL POLARIS ULTRA 5X20,4201858,CDM,270,RC,,,OUTPATIENT,,,574,344.4,,487.9,85,,390.32,Percent of total billed charges,85% of total billed charges,287,50,,229.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,287,50,,229.6,percent of total billed charges,50% of total billed charges,183.39,31.95,,146.712,percent of total billed charges,31.95% of total billed charges,183.39,31.95,,146.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,218.12,38,,592.8,percent of total billed charges,38% of total billed charges,229.6,40,,183.68,percent of total billed charges,40% of total billed charges,4219.94,5871,
CYSTO IRRIGATION SINGLE TUBE FOR BOTTLE IRRIG,4201859,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,224.96,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4220.94,5872,
FMC INJECTOR SYRINGE ASSEMBLY,4201860,CDM,270,RC,,,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38,38,,680.96,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,4221.94,5873,
OMNIPAQUE CONTRAST,4201861,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,592.8,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4222.94,5874,
FMC OMNIPAQUE CT CONTRAST,4201861,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,121.6,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4223.94,5875,
ARMBOARD WRIST,4201865,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,547.2,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4224.94,5876,
"SPLINT, TIB FIB HIP CHILD",4201866,CDM,270,RC,,,OUTPATIENT,,,112.86,67.716,,95.93,85,,76.744,Percent of total billed charges,85% of total billed charges,56.43,50,,45.144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.43,50,,45.144,percent of total billed charges,50% of total billed charges,36.06,31.95,,28.848,percent of total billed charges,31.95% of total billed charges,36.06,31.95,,28.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.89,38,,820.8,percent of total billed charges,38% of total billed charges,45.14,40,,36.112,percent of total billed charges,40% of total billed charges,4225.94,5877,
"SPLINT, TIB FIB HIP YOUTH",4201868,CDM,270,RC,,,OUTPATIENT,,,84,50.4,,71.4,85,,57.12,Percent of total billed charges,85% of total billed charges,42,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42,50,,33.6,percent of total billed charges,50% of total billed charges,26.84,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,26.84,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.92,38,,228,percent of total billed charges,38% of total billed charges,33.6,40,,26.88,percent of total billed charges,40% of total billed charges,4226.94,5878,
INFLATOR SINGLE SHOT CUFF,4201869,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,1094.4,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4227.94,5879,
DPT MONITORING KIT,4201882,CDM,270,RC,,,OUTPATIENT,,,37.8,22.68,,32.13,85,,25.704,Percent of total billed charges,85% of total billed charges,18.9,50,,15.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.9,50,,15.12,percent of total billed charges,50% of total billed charges,12.08,31.95,,9.664,percent of total billed charges,31.95% of total billed charges,12.08,31.95,,9.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.36,38,,592.8,percent of total billed charges,38% of total billed charges,15.12,40,,12.096,percent of total billed charges,40% of total billed charges,4228.94,5880,
ARM SLING MED,4201883,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,3.16,35.15,,2.528,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,1231.2,percent of total billed charges,38% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,4229.94,5881,
ABDOMINAL BINDER 12'''',4201884,CDM,270,RC,A4461,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,8.79,35.15,,7.032,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,4.5,100,,,fee schedule,100% of CMS custom fee schedule,9.5,38,,592.8,percent of total billed charges,38% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,4230.94,5882,
CLAVICLE SPLINT PADDED XSM,4201889,CDM,270,RC,L3650,HCPCS,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,9.49,35.15,,7.592,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,69.97,100,,,fee schedule,100% of CMS custom fee schedule,10.26,38,,545.68,percent of total billed charges,38% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,4231.94,5883,
CAST PADDING 2'''',4201891,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,24.32,percent of total billed charges,38% of total billed charges,0.8,40,,0.64,percent of total billed charges,40% of total billed charges,4232.94,5884,
CAST PADDING 4'''',4201892,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,13.68,percent of total billed charges,38% of total billed charges,0.8,40,,0.64,percent of total billed charges,40% of total billed charges,4233.94,5885,
CAST PADDING 6'''',4201893,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,132.848,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4234.94,5886,
MICRO-DROP 60GTT ANESTHESIA PEDIATRIC TUBING,4201896,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,117.952,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4235.94,5887,
STAPLER 25MM CIRCULAR ILS,4201897,CDM,270,RC,,,OUTPATIENT,,,980,588,,833,85,,666.4,Percent of total billed charges,85% of total billed charges,490,50,,392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,490,50,,392,percent of total billed charges,50% of total billed charges,313.11,31.95,,250.488,percent of total billed charges,31.95% of total billed charges,313.11,31.95,,250.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,372.4,38,,276.64,percent of total billed charges,38% of total billed charges,392,40,,313.6,percent of total billed charges,40% of total billed charges,4236.94,5888,
LIGASURE CUR SM JAW SEALER/DIVIDER,4201898,CDM,270,RC,,,OUTPATIENT,,,1344,806.4,,1142.4,85,,913.92,Percent of total billed charges,85% of total billed charges,672,50,,537.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,672,50,,537.6,percent of total billed charges,50% of total billed charges,429.41,31.95,,343.528,percent of total billed charges,31.95% of total billed charges,429.41,31.95,,343.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,510.72,38,,1222.08,percent of total billed charges,38% of total billed charges,537.6,40,,430.08,percent of total billed charges,40% of total billed charges,4237.94,5889,
SUTURE ETHIBOND 2.0,4201899,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,54.72,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4238.94,5890,
SUTURE 3.0 VICRYL,4201900,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,42.56,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4239.94,5891,
SUTURE 2.0 VICRYL,4201901,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,42.56,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4240.94,5892,
NEEDLE BIOPSY 18GX10CM 22MM MAXCORE,4201905,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,88.16,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4241.94,5893,
FMC NDLBIOP 18GX10CM 22MM MXCR,4201905,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,501.6,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4242.94,5894,
NEEDLE BIOPSY 18GX26CM 22MM MAXCORE,4201906,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,120.688,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4243.94,5895,
FMC NDLBIOP 18GX16CM 22MM MXCR,4201906,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,66.88,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4244.94,5896,
NEEDLE BIOPSY 16GX16CM 22MM MAXCORE,4201907,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,547.808,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4245.94,5897,
FMC NDLBIOP 16GX16CM 22MM MXCR,4201907,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,547.808,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4246.94,5898,
NEEDLE BIOPSY 16GX10CM 22MM MAXCORE,4201908,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,547.808,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4247.94,5899,
FMC NDLBIOP 16GX10CM 22MM MXCR,4201908,CDM,270,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,7.904,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4248.94,5900,
GUIDE BIOPSY TRUGUIDE 17GX13.8CM,4201909,CDM,270,RC,,,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108,50,,86.4,percent of total billed charges,50% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.08,38,,45.6,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,4249.94,5901,
FMC BIOPSY TRUGUIDE 17GX13.8CM,4201909,CDM,270,RC,,,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108,50,,86.4,percent of total billed charges,50% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.08,38,,547.2,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,4250.94,5902,
GUIDE BIOPSY TRUGUIDE 17GX7.8CM,4201910,CDM,270,RC,,,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108,50,,86.4,percent of total billed charges,50% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.08,38,,1094.4,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,4251.94,5903,
FMC BIOPSY TRUGUIDE 17GX7.8CM,4201910,CDM,270,RC,,,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108,50,,86.4,percent of total billed charges,50% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.08,38,,63.84,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,4252.94,5904,
GUIDE BIOPSY TRUGUIDE 15GX7.8CM,4201911,CDM,270,RC,,,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108,50,,86.4,percent of total billed charges,50% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.08,38,,74.176,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,4253.94,5905,
FMC BIOPSY TRUGUIDE 15GX7.8CM,4201911,CDM,270,RC,,,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,108,50,,86.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108,50,,86.4,percent of total billed charges,50% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.08,38,,939.36,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,4254.94,5906,
BREAST LOCALIZATION WIRE 20GX107MM DUALOK,4201913,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,88.768,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4255.94,5907,
FMC BREAST LC 20GX107MM DUALOK,4201913,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,97.28,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4256.94,5908,
BREAST LOCALIZATION WIRE 20GX77MM DUALOK,4201914,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,97.28,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4257.94,5909,
FMC BREAST LOC 20GX77MM DUALOK,4201914,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,91.2,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4258.94,5910,
CRE WIRE GUIDED ESOPHAGEAL/COLONIC (18-20MM),4201916,CDM,270,RC,,,OUTPATIENT,,,289,173.4,,245.65,85,,196.52,Percent of total billed charges,85% of total billed charges,144.5,50,,115.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,144.5,50,,115.6,percent of total billed charges,50% of total billed charges,92.34,31.95,,73.872,percent of total billed charges,31.95% of total billed charges,92.34,31.95,,73.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,109.82,38,,592.8,percent of total billed charges,38% of total billed charges,115.6,40,,92.48,percent of total billed charges,40% of total billed charges,4259.94,5911,
CRE WIRE GUIDED ESOPHAGEAL/COLONIC (15-18MM),4201917,CDM,270,RC,,,OUTPATIENT,,,289,173.4,,245.65,85,,196.52,Percent of total billed charges,85% of total billed charges,144.5,50,,115.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,144.5,50,,115.6,percent of total billed charges,50% of total billed charges,92.34,31.95,,73.872,percent of total billed charges,31.95% of total billed charges,92.34,31.95,,73.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,109.82,38,,60.8,percent of total billed charges,38% of total billed charges,115.6,40,,92.48,percent of total billed charges,40% of total billed charges,4260.94,5912,
BREAST LOCALIZATION WIRE 20GX57MM DUALOK,4201920,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,1687.2,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4261.94,5913,
FMC BREAST LOC 20GX57MM DUALOK,4201920,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,661.2,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4262.94,5914,
GUIDE BIOPSY TRUGUIDE 15X13.8CM,4201921,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,106.4,percent of total billed charges,38% of total billed charges,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,4263.94,5915,
FMC BIOPSY TRUGUIDE 15X13.8CM,4201921,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,106.4,percent of total billed charges,38% of total billed charges,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,4264.94,5916,
AUTOGUARD INSYTE 20GX1.88'''',4201922,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,102.752,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4265.94,5917,
BOVIE TIP 2.5MM,4201923,CDM,270,RC,,,OUTPATIENT,,,18.83,11.298,,16.01,85,,12.808,Percent of total billed charges,85% of total billed charges,9.42,50,,7.536,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.42,50,,7.536,percent of total billed charges,50% of total billed charges,6.02,31.95,,4.816,percent of total billed charges,31.95% of total billed charges,6.02,31.95,,4.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.16,38,,708.016,percent of total billed charges,38% of total billed charges,7.53,40,,6.024,percent of total billed charges,40% of total billed charges,4266.94,5918,
TROCAR BLADELESS 5MM 100MM,4201926,CDM,270,RC,,,OUTPATIENT,,,252,151.2,,214.2,85,,171.36,Percent of total billed charges,85% of total billed charges,126,50,,100.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,126,50,,100.8,percent of total billed charges,50% of total billed charges,80.51,31.95,,64.408,percent of total billed charges,31.95% of total billed charges,80.51,31.95,,64.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95.76,38,,91.2,percent of total billed charges,38% of total billed charges,100.8,40,,80.64,percent of total billed charges,40% of total billed charges,4267.94,5919,
BARIUM EZHD 764,4201928,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,91.2,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4268.94,5920,
FMC BARIUM E-Z HD,4201928,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,91.2,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4269.94,5921,
BARIUM POLIBAR L168,4201929,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,91.2,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4270.94,5922,
FMC BARIUM POLIBAR,4201929,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,547.2,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4271.94,5923,
BAG BARIUM SUPER XL 8925,4201930,CDM,270,RC,,,OUTPATIENT,,,23,13.8,,19.55,85,,15.64,Percent of total billed charges,85% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.74,38,,122.208,percent of total billed charges,38% of total billed charges,9.2,40,,7.36,percent of total billed charges,40% of total billed charges,4272.94,5924,
FMC BAG BARIUM XL,4201930,CDM,270,RC,,,OUTPATIENT,,,23,13.8,,19.55,85,,15.64,Percent of total billed charges,85% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.74,38,,45.6,percent of total billed charges,38% of total billed charges,9.2,40,,7.36,percent of total billed charges,40% of total billed charges,4273.94,5925,
ESOPHAGEAL BALLOON DILATATION CATHETER,4201931,CDM,270,RC,,,OUTPATIENT,,,800,480,,680,85,,544,Percent of total billed charges,85% of total billed charges,400,50,,320,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,400,50,,320,percent of total billed charges,50% of total billed charges,255.6,31.95,,204.48,percent of total billed charges,31.95% of total billed charges,255.6,31.95,,204.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,304,38,,45.6,percent of total billed charges,38% of total billed charges,320,40,,256,percent of total billed charges,40% of total billed charges,4274.94,5926,
SYRINGE SINGLE-USE/GUAGE ASSEMBLY,4201932,CDM,270,RC,,,OUTPATIENT,,,196,117.6,,166.6,85,,133.28,Percent of total billed charges,85% of total billed charges,98,50,,78.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,98,50,,78.4,percent of total billed charges,50% of total billed charges,62.62,31.95,,50.096,percent of total billed charges,31.95% of total billed charges,62.62,31.95,,50.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,74.48,38,,1687.2,percent of total billed charges,38% of total billed charges,78.4,40,,62.72,percent of total billed charges,40% of total billed charges,4275.94,5927,
GRID LINE CT BIOPSY,4201933,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,661.2,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4276.94,5928,
FMC CT-GUIDELINES LARGE,4201933,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,103.36,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4277.94,5929,
HEATED TUBESET WITH RTP FOR PNEUMOSURE,4201934,CDM,270,RC,,,OUTPATIENT,,,178,106.8,,151.3,85,,121.04,Percent of total billed charges,85% of total billed charges,89,50,,71.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,89,50,,71.2,percent of total billed charges,50% of total billed charges,56.87,31.95,,45.496,percent of total billed charges,31.95% of total billed charges,56.87,31.95,,45.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,67.64,38,,390.64,percent of total billed charges,38% of total billed charges,71.2,40,,56.96,percent of total billed charges,40% of total billed charges,4278.94,5930,
BRIEF MESH XL SURGICAL,4201935,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,104.88,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4279.94,5931,
NEEDLE SPINAL 20GX3.5'''',4201936,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,104.88,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4280.94,5932,
FMC NEEDLE SPINAL 20GX3.5,4201936,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,104.88,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4281.94,5933,
CLOSED WOUND SUCTION KIT,4201937,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,104.88,percent of total billed charges,38% of total billed charges,11.2,40,,8.96,percent of total billed charges,40% of total billed charges,4282.94,5934,
FMC CLOSED WOUND SUCTION KIT,4201937,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,45.6,percent of total billed charges,38% of total billed charges,11.2,40,,8.96,percent of total billed charges,40% of total billed charges,4283.94,5935,
DRESSING 4X4 FIBRACOL PLS COLLAGEN W/ALGINATE,4201938,CDM,270,RC,,,OUTPATIENT,,,41.82,25.092,,35.55,85,,28.44,Percent of total billed charges,85% of total billed charges,20.91,50,,16.728,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.91,50,,16.728,percent of total billed charges,50% of total billed charges,13.36,31.95,,10.688,percent of total billed charges,31.95% of total billed charges,13.36,31.95,,10.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.89,38,,45.6,percent of total billed charges,38% of total billed charges,16.73,40,,13.384,percent of total billed charges,40% of total billed charges,4284.94,5936,
DRAINAGE KIT (LOCKING PIGTAIL),4201939,CDM,270,RC,,,OUTPATIENT,,,444,266.4,,377.4,85,,301.92,Percent of total billed charges,85% of total billed charges,222,50,,177.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,222,50,,177.6,percent of total billed charges,50% of total billed charges,141.86,31.95,,113.488,percent of total billed charges,31.95% of total billed charges,141.86,31.95,,113.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,168.72,38,,144.4,percent of total billed charges,38% of total billed charges,177.6,40,,142.08,percent of total billed charges,40% of total billed charges,4285.94,5937,
FMC DRAIN KIT-LOCKING PIGTAIL,4201939,CDM,270,RC,,,OUTPATIENT,,,444,266.4,,377.4,85,,301.92,Percent of total billed charges,85% of total billed charges,222,50,,177.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,222,50,,177.6,percent of total billed charges,50% of total billed charges,141.86,31.95,,113.488,percent of total billed charges,31.95% of total billed charges,141.86,31.95,,113.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,168.72,38,,136.8,percent of total billed charges,38% of total billed charges,177.6,40,,142.08,percent of total billed charges,40% of total billed charges,4286.94,5938,
D-BAG DRAINAGE SET,4201940,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,456,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4287.94,5939,
FMC D-BAG DRAINAGE SET,4201940,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,104.88,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4288.94,5940,
BRIEF MESH MED. SURGICAL,4201941,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,410.4,percent of total billed charges,38% of total billed charges,0.8,40,,0.64,percent of total billed charges,40% of total billed charges,4289.94,5941,
SLEEVE STABILITY 5MM FOR TROCAR,4201942,CDM,270,RC,,,OUTPATIENT,,,82.75,49.65,,70.34,85,,56.272,Percent of total billed charges,85% of total billed charges,41.38,50,,33.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,41.38,50,,33.104,percent of total billed charges,50% of total billed charges,26.44,31.95,,21.152,percent of total billed charges,31.95% of total billed charges,26.44,31.95,,21.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.45,38,,278.16,percent of total billed charges,38% of total billed charges,33.1,40,,26.48,percent of total billed charges,40% of total billed charges,4290.94,5942,
SLEEVE STABILITY 12MM FOR TROCAR,4201943,CDM,270,RC,,,OUTPATIENT,,,34.86,20.916,,29.63,85,,23.704,Percent of total billed charges,85% of total billed charges,17.43,50,,13.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.43,50,,13.944,percent of total billed charges,50% of total billed charges,11.14,31.95,,8.912,percent of total billed charges,31.95% of total billed charges,11.14,31.95,,8.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.25,38,,142.88,percent of total billed charges,38% of total billed charges,13.94,40,,11.152,percent of total billed charges,40% of total billed charges,4291.94,5943,
TROCAR 5MM 100MM LENGTH,4201946,CDM,270,RC,,,OUTPATIENT,,,45.89,27.534,,39.01,85,,31.208,Percent of total billed charges,85% of total billed charges,22.95,50,,18.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.95,50,,18.36,percent of total billed charges,50% of total billed charges,14.66,31.95,,11.728,percent of total billed charges,31.95% of total billed charges,14.66,31.95,,11.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.44,38,,296.4,percent of total billed charges,38% of total billed charges,18.36,40,,14.688,percent of total billed charges,40% of total billed charges,4292.94,5944,
TROCAR 12MM 150MM LENGTH,4201947,CDM,270,RC,,,OUTPATIENT,,,70.45,42.27,,59.88,85,,47.904,Percent of total billed charges,85% of total billed charges,35.23,50,,28.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.23,50,,28.184,percent of total billed charges,50% of total billed charges,22.51,31.95,,18.008,percent of total billed charges,31.95% of total billed charges,22.51,31.95,,18.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.77,38,,103.36,percent of total billed charges,38% of total billed charges,28.18,40,,22.544,percent of total billed charges,40% of total billed charges,4293.94,5945,
120MM VERESS NEEDLE,4201948,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,16.72,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4294.94,5946,
ENDOLOOP VICRYL LIGATURE,4201949,CDM,270,RC,,,OUTPATIENT,,,42.35,25.41,,36,85,,28.8,Percent of total billed charges,85% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,13.53,31.95,,10.824,percent of total billed charges,31.95% of total billed charges,13.53,31.95,,10.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.09,38,,1231.2,percent of total billed charges,38% of total billed charges,16.94,40,,13.552,percent of total billed charges,40% of total billed charges,4295.94,5947,
ENDOLOOP PDS II LIGATURE,4201950,CDM,270,RC,,,OUTPATIENT,,,42.35,25.41,,36,85,,28.8,Percent of total billed charges,85% of total billed charges,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.18,50,,16.944,percent of total billed charges,50% of total billed charges,13.53,31.95,,10.824,percent of total billed charges,31.95% of total billed charges,13.53,31.95,,10.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.09,38,,592.8,percent of total billed charges,38% of total billed charges,16.94,40,,13.552,percent of total billed charges,40% of total billed charges,4296.94,5948,
DISSECTOR 5MM ENDOSCOPIC BLUNT,4201951,CDM,270,RC,,,OUTPATIENT,,,61.48,36.888,,52.26,85,,41.808,Percent of total billed charges,85% of total billed charges,30.74,50,,24.592,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.74,50,,24.592,percent of total billed charges,50% of total billed charges,19.64,31.95,,15.712,percent of total billed charges,31.95% of total billed charges,19.64,31.95,,15.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.36,38,,273.6,percent of total billed charges,38% of total billed charges,24.59,40,,19.672,percent of total billed charges,40% of total billed charges,4297.94,5949,
NUROLON 0.0 SUTURE,4201952,CDM,270,RC,,,OUTPATIENT,,,40.3,24.18,,34.26,85,,27.408,Percent of total billed charges,85% of total billed charges,20.15,50,,16.12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.15,50,,16.12,percent of total billed charges,50% of total billed charges,12.88,31.95,,10.304,percent of total billed charges,31.95% of total billed charges,12.88,31.95,,10.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.31,38,,775.2,percent of total billed charges,38% of total billed charges,16.12,40,,12.896,percent of total billed charges,40% of total billed charges,4298.94,5950,
SUTURE 4.0 MONOCRYL PC5  PC12,4201953,CDM,270,RC,,,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.14,38,,1231.2,percent of total billed charges,38% of total billed charges,21.2,40,,16.96,percent of total billed charges,40% of total billed charges,4299.94,5951,
SLEEVE STABLTY EXCEL 5MM DIA 100MM,4201954,CDM,270,RC,,,OUTPATIENT,,,27.57,16.542,,23.43,85,,18.744,Percent of total billed charges,85% of total billed charges,13.79,50,,11.032,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.79,50,,11.032,percent of total billed charges,50% of total billed charges,8.81,31.95,,7.048,percent of total billed charges,31.95% of total billed charges,8.81,31.95,,7.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.48,38,,322.24,percent of total billed charges,38% of total billed charges,11.03,40,,8.824,percent of total billed charges,40% of total billed charges,4300.94,5952,
5FR. ROUND TIP URETERAL CATHETER,4201955,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,592.8,percent of total billed charges,38% of total billed charges,14,40,,11.2,percent of total billed charges,40% of total billed charges,4301.94,5953,
SUTURE 4.0 CHROMIC GUT CV-25,4201956,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,139.84,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4302.94,5954,
INCONTINENCE CLAMP REGULAR SIZE,4201957,CDM,270,RC,,,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.6,38,,139.84,percent of total billed charges,38% of total billed charges,28,40,,22.4,percent of total billed charges,40% of total billed charges,4303.94,5955,
TAMPONADE ANTERIOR/POSTERIOR,4201958,CDM,270,RC,,,OUTPATIENT,,,221,132.6,,187.85,85,,150.28,Percent of total billed charges,85% of total billed charges,110.5,50,,88.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,110.5,50,,88.4,percent of total billed charges,50% of total billed charges,70.61,31.95,,56.488,percent of total billed charges,31.95% of total billed charges,70.61,31.95,,56.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,83.98,38,,42.56,percent of total billed charges,38% of total billed charges,88.4,40,,70.72,percent of total billed charges,40% of total billed charges,4304.94,5956,
INFUSION SET POWERLOC SAFETY W/Y INJECT SET,4201959,CDM,270,RC,,,OUTPATIENT,,,67.5,40.5,,57.38,85,,45.904,Percent of total billed charges,85% of total billed charges,33.75,50,,27,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.75,50,,27,percent of total billed charges,50% of total billed charges,21.57,31.95,,17.256,percent of total billed charges,31.95% of total billed charges,21.57,31.95,,17.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.65,38,,88.768,percent of total billed charges,38% of total billed charges,27,40,,21.6,percent of total billed charges,40% of total billed charges,4305.94,5957,
DRESSING TUBIGRIP SIZE E,4201960,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,88.768,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4306.94,5958,
BIOPSY IC5-9-D NEEDLE GUIDE KIT,4201961,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,88.768,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,4307.94,5959,
SUTURE 6.0 PROLENE CC-1 KV11,4201963,CDM,270,RC,,,OUTPATIENT,,,17.5,10.5,,14.88,85,,11.904,Percent of total billed charges,85% of total billed charges,8.75,50,,7,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.75,50,,7,percent of total billed charges,50% of total billed charges,5.59,31.95,,4.472,percent of total billed charges,31.95% of total billed charges,5.59,31.95,,4.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.65,38,,88.768,percent of total billed charges,38% of total billed charges,7,40,,5.6,percent of total billed charges,40% of total billed charges,4308.94,5960,
SUTURE 5.0 PROLENE CC-1 KV-11,4201964,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,547.808,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4309.94,5961,
ENDO CLOSE SITE TROCAR CLOSURE DEVICE,4201965,CDM,270,RC,,,OUTPATIENT,,,196,117.6,,166.6,85,,133.28,Percent of total billed charges,85% of total billed charges,98,50,,78.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,98,50,,78.4,percent of total billed charges,50% of total billed charges,62.62,31.95,,50.096,percent of total billed charges,31.95% of total billed charges,62.62,31.95,,50.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,74.48,38,,547.808,percent of total billed charges,38% of total billed charges,78.4,40,,62.72,percent of total billed charges,40% of total billed charges,4310.94,5962,
PROMOGRAN DRESSING 4.1'''',4201967,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,501.6,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4311.94,5963,
SHOULDER IMMOBILIZER VELPEAU DRESSING XL,4201968,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,312.816,percent of total billed charges,38% of total billed charges,5.6,40,,4.48,percent of total billed charges,40% of total billed charges,4312.94,5964,
MAGNUM CORE TISSUE BIOPSY NEEDLE 18G,4201969,CDM,270,RC,A4215,HCPCS,OUTPATIENT,,,84,50.4,,71.4,85,,57.12,Percent of total billed charges,85% of total billed charges,42,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42,50,,33.6,percent of total billed charges,50% of total billed charges,29.53,35.15,,23.624,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.92,38,,3088.032,percent of total billed charges,38% of total billed charges,26.84,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,4313.94,5965,
CURVED SHEARS HARMONIC FOCUS 9CM ADAPTIVE,4201970,CDM,270,RC,,,OUTPATIENT,,,2130,1278,,1810.5,85,,1448.4,Percent of total billed charges,85% of total billed charges,1065,50,,852,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1065,50,,852,percent of total billed charges,50% of total billed charges,680.54,31.95,,544.432,percent of total billed charges,31.95% of total billed charges,680.54,31.95,,544.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,809.4,38,,410.4,percent of total billed charges,38% of total billed charges,852,40,,681.6,percent of total billed charges,40% of total billed charges,4314.94,5966,
TROCAR THORACIC CATHETER 10FR,4201971,CDM,270,RC,,,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,11.82,31.95,,9.456,percent of total billed charges,31.95% of total billed charges,11.82,31.95,,9.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.06,38,,592.8,percent of total billed charges,38% of total billed charges,14.8,40,,11.84,percent of total billed charges,40% of total billed charges,4315.94,5967,
HERNIA SYSTEM MEDIUM,4201972,CDM,270,RC,,,OUTPATIENT,,,2192.32,1315.392,,1863.47,85,,1490.776,Percent of total billed charges,85% of total billed charges,1096.16,50,,876.928,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1096.16,50,,876.928,percent of total billed charges,50% of total billed charges,700.45,31.95,,560.36,percent of total billed charges,31.95% of total billed charges,700.45,31.95,,560.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,833.08,38,,124.944,percent of total billed charges,38% of total billed charges,876.93,40,,701.544,percent of total billed charges,40% of total billed charges,4316.94,5968,
HERNIA SYSTEM OVAL,4201973,CDM,270,RC,,,OUTPATIENT,,,1096.16,657.696,,931.74,85,,745.392,Percent of total billed charges,85% of total billed charges,548.08,50,,438.464,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,548.08,50,,438.464,percent of total billed charges,50% of total billed charges,350.22,31.95,,280.176,percent of total billed charges,31.95% of total billed charges,350.22,31.95,,280.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,416.54,38,,78.432,percent of total billed charges,38% of total billed charges,438.46,40,,350.768,percent of total billed charges,40% of total billed charges,4317.94,5969,
CUTTER 60 ARTICULATING,4201974,CDM,270,RC,,,OUTPATIENT,,,422.96,253.776,,359.52,85,,287.616,Percent of total billed charges,85% of total billed charges,211.48,50,,169.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,211.48,50,,169.184,percent of total billed charges,50% of total billed charges,135.14,31.95,,108.112,percent of total billed charges,31.95% of total billed charges,135.14,31.95,,108.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,160.72,38,,854.24,percent of total billed charges,38% of total billed charges,169.18,40,,135.344,percent of total billed charges,40% of total billed charges,4318.94,5970,
STAPLER RELOAD 60 BLUE,4201975,CDM,270,RC,,,OUTPATIENT,,,149.49,89.694,,127.07,85,,101.656,Percent of total billed charges,85% of total billed charges,74.75,50,,59.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,74.75,50,,59.8,percent of total billed charges,50% of total billed charges,47.76,31.95,,38.208,percent of total billed charges,31.95% of total billed charges,47.76,31.95,,38.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,56.81,38,,105.792,percent of total billed charges,38% of total billed charges,59.8,40,,47.84,percent of total billed charges,40% of total billed charges,4319.94,5971,
CUTTER 60MM ECHELON FLEX LONG,4201976,CDM,270,RC,,,OUTPATIENT,,,403.22,241.932,,342.74,85,,274.192,Percent of total billed charges,85% of total billed charges,201.61,50,,161.288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,201.61,50,,161.288,percent of total billed charges,50% of total billed charges,128.83,31.95,,103.064,percent of total billed charges,31.95% of total billed charges,128.83,31.95,,103.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,153.22,38,,105.792,percent of total billed charges,38% of total billed charges,161.29,40,,129.032,percent of total billed charges,40% of total billed charges,4320.94,5972,
CUTTER 55MM PROXIMATE,4201978,CDM,270,RC,,,OUTPATIENT,,,125.67,75.402,,106.82,85,,85.456,Percent of total billed charges,85% of total billed charges,62.84,50,,50.272,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,62.84,50,,50.272,percent of total billed charges,50% of total billed charges,40.15,31.95,,32.12,percent of total billed charges,31.95% of total billed charges,40.15,31.95,,32.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.75,38,,105.792,percent of total billed charges,38% of total billed charges,50.27,40,,40.216,percent of total billed charges,40% of total billed charges,4321.94,5973,
CUTTER 55MM LINEAR TITANIUM,4201979,CDM,270,RC,,,OUTPATIENT,,,118.25,70.95,,100.51,85,,80.408,Percent of total billed charges,85% of total billed charges,59.13,50,,47.304,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,59.13,50,,47.304,percent of total billed charges,50% of total billed charges,37.78,31.95,,30.224,percent of total billed charges,31.95% of total billed charges,37.78,31.95,,30.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.94,38,,105.792,percent of total billed charges,38% of total billed charges,47.3,40,,37.84,percent of total billed charges,40% of total billed charges,4322.94,5974,
CUTTER 55MM LINEAR THICK TISSUE,4201980,CDM,270,RC,,,OUTPATIENT,,,124.07,74.442,,105.46,85,,84.368,Percent of total billed charges,85% of total billed charges,62.04,50,,49.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,62.04,50,,49.632,percent of total billed charges,50% of total billed charges,39.64,31.95,,31.712,percent of total billed charges,31.95% of total billed charges,39.64,31.95,,31.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.15,38,,547.808,percent of total billed charges,38% of total billed charges,49.63,40,,39.704,percent of total billed charges,40% of total billed charges,4323.94,5975,
CUTTER 75MM LINEAR TITANIUM,4201981,CDM,270,RC,,,OUTPATIENT,,,176.73,106.038,,150.22,85,,120.176,Percent of total billed charges,85% of total billed charges,88.37,50,,70.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,88.37,50,,70.696,percent of total billed charges,50% of total billed charges,56.47,31.95,,45.176,percent of total billed charges,31.95% of total billed charges,56.47,31.95,,45.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,67.16,38,,1094.4,percent of total billed charges,38% of total billed charges,70.69,40,,56.552,percent of total billed charges,40% of total billed charges,4324.94,5976,
CLIP 5MM APPLIER LIGAMAX,4201983,CDM,270,RC,,,OUTPATIENT,,,186.31,111.786,,158.36,85,,126.688,Percent of total billed charges,85% of total billed charges,93.16,50,,74.528,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,93.16,50,,74.528,percent of total billed charges,50% of total billed charges,59.53,31.95,,47.624,percent of total billed charges,31.95% of total billed charges,59.53,31.95,,47.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.8,38,,457.216,percent of total billed charges,38% of total billed charges,74.52,40,,59.616,percent of total billed charges,40% of total billed charges,4325.94,5977,
STAPLER 12MM RELOAD GREEN,4201984,CDM,270,RC,,,OUTPATIENT,,,149.44,89.664,,127.02,85,,101.616,Percent of total billed charges,85% of total billed charges,74.72,50,,59.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,74.72,50,,59.776,percent of total billed charges,50% of total billed charges,47.75,31.95,,38.2,percent of total billed charges,31.95% of total billed charges,47.75,31.95,,38.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,56.79,38,,91.2,percent of total billed charges,38% of total billed charges,59.78,40,,47.824,percent of total billed charges,40% of total billed charges,4326.94,5978,
RELOAD 6MM FLEX 60 WHITE,4201985,CDM,270,RC,,,OUTPATIENT,,,167.49,100.494,,142.37,85,,113.896,Percent of total billed charges,85% of total billed charges,83.75,50,,67,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,83.75,50,,67,percent of total billed charges,50% of total billed charges,53.51,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,53.51,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.65,38,,273.6,percent of total billed charges,38% of total billed charges,67,40,,53.6,percent of total billed charges,40% of total billed charges,4327.94,5979,
RELOAD 6MM FLEX 60 BLUE,4201986,CDM,270,RC,,,OUTPATIENT,,,167.49,100.494,,142.37,85,,113.896,Percent of total billed charges,85% of total billed charges,83.75,50,,67,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,83.75,50,,67,percent of total billed charges,50% of total billed charges,53.51,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,53.51,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.65,38,,273.6,percent of total billed charges,38% of total billed charges,67,40,,53.6,percent of total billed charges,40% of total billed charges,4328.94,5980,
CUTTER RELOAD 45MM ETS LINEAR,4201988,CDM,270,RC,,,OUTPATIENT,,,128.39,77.034,,109.13,85,,87.304,Percent of total billed charges,85% of total billed charges,64.2,50,,51.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.2,50,,51.36,percent of total billed charges,50% of total billed charges,41.02,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,41.02,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.79,38,,661.2,percent of total billed charges,38% of total billed charges,51.36,40,,41.088,percent of total billed charges,40% of total billed charges,4329.94,5981,
RELOAD 45M CUTTER 45MM GREEN,4201989,CDM,270,RC,,,OUTPATIENT,,,128.39,77.034,,109.13,85,,87.304,Percent of total billed charges,85% of total billed charges,64.2,50,,51.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.2,50,,51.36,percent of total billed charges,50% of total billed charges,41.02,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,41.02,31.95,,32.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.79,38,,45.6,percent of total billed charges,38% of total billed charges,51.36,40,,41.088,percent of total billed charges,40% of total billed charges,4330.94,5982,
CUTTER 55MM LINEAR PROXIMATE,4201990,CDM,270,RC,,,OUTPATIENT,,,70.05,42.03,,59.54,85,,47.632,Percent of total billed charges,85% of total billed charges,35.03,50,,28.024,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.03,50,,28.024,percent of total billed charges,50% of total billed charges,22.38,31.95,,17.904,percent of total billed charges,31.95% of total billed charges,22.38,31.95,,17.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.62,38,,146.528,percent of total billed charges,38% of total billed charges,28.02,40,,22.416,percent of total billed charges,40% of total billed charges,4331.94,5983,
CUTTER 75MM LINEAR,4201991,CDM,270,RC,,,OUTPATIENT,,,192.48,115.488,,163.61,85,,130.888,Percent of total billed charges,85% of total billed charges,96.24,50,,76.992,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.24,50,,76.992,percent of total billed charges,50% of total billed charges,61.5,31.95,,49.2,percent of total billed charges,31.95% of total billed charges,61.5,31.95,,49.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.14,38,,273.6,percent of total billed charges,38% of total billed charges,76.99,40,,61.592,percent of total billed charges,40% of total billed charges,4332.94,5984,
CARTRIDGE 75MM RELOAD,4201993,CDM,270,RC,,,OUTPATIENT,,,94.24,56.544,,80.1,85,,64.08,Percent of total billed charges,85% of total billed charges,47.12,50,,37.696,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47.12,50,,37.696,percent of total billed charges,50% of total billed charges,30.11,31.95,,24.088,percent of total billed charges,31.95% of total billed charges,30.11,31.95,,24.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.81,38,,899.84,percent of total billed charges,38% of total billed charges,37.7,40,,30.16,percent of total billed charges,40% of total billed charges,4333.94,5985,
CUTTER RELOADING PROX,4201994,CDM,270,RC,,,OUTPATIENT,,,96.09,57.654,,81.68,85,,65.344,Percent of total billed charges,85% of total billed charges,48.05,50,,38.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48.05,50,,38.44,percent of total billed charges,50% of total billed charges,30.7,31.95,,24.56,percent of total billed charges,31.95% of total billed charges,30.7,31.95,,24.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.51,38,,88.768,percent of total billed charges,38% of total billed charges,38.44,40,,30.752,percent of total billed charges,40% of total billed charges,4334.94,5986,
RELOAD 6MM ETS FLEX 60 GREEN,4201995,CDM,270,RC,,,OUTPATIENT,,,167.49,100.494,,142.37,85,,113.896,Percent of total billed charges,85% of total billed charges,83.75,50,,67,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,83.75,50,,67,percent of total billed charges,50% of total billed charges,53.51,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,53.51,31.95,,42.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.65,38,,796.784,percent of total billed charges,38% of total billed charges,67,40,,53.6,percent of total billed charges,40% of total billed charges,4335.94,5987,
STAPLER 29MM CIRCULAR ILS,4201996,CDM,270,RC,,,OUTPATIENT,,,572.87,343.722,,486.94,85,,389.552,Percent of total billed charges,85% of total billed charges,286.44,50,,229.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,286.44,50,,229.152,percent of total billed charges,50% of total billed charges,183.03,31.95,,146.424,percent of total billed charges,31.95% of total billed charges,183.03,31.95,,146.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,217.69,38,,1094.4,percent of total billed charges,38% of total billed charges,229.15,40,,183.32,percent of total billed charges,40% of total billed charges,4336.94,5988,
STAPLER 33MM CIRCULAR ILS,4201997,CDM,270,RC,,,OUTPATIENT,,,572.87,343.722,,486.94,85,,389.552,Percent of total billed charges,85% of total billed charges,286.44,50,,229.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,286.44,50,,229.152,percent of total billed charges,50% of total billed charges,183.03,31.95,,146.424,percent of total billed charges,31.95% of total billed charges,183.03,31.95,,146.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,217.69,38,,501.6,percent of total billed charges,38% of total billed charges,229.15,40,,183.32,percent of total billed charges,40% of total billed charges,4337.94,5989,
SUTURE 0.0 POLYSORB GU-45,4201998,CDM,270,RC,,,OUTPATIENT,,,13.88,8.328,,11.8,85,,9.44,Percent of total billed charges,85% of total billed charges,6.94,50,,5.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.94,50,,5.552,percent of total billed charges,50% of total billed charges,4.43,31.95,,3.544,percent of total billed charges,31.95% of total billed charges,4.43,31.95,,3.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.27,38,,273.6,percent of total billed charges,38% of total billed charges,5.55,40,,4.44,percent of total billed charges,40% of total billed charges,4338.94,5990,
SUTURE 2.0 MONOSOFT SF-1 C-15,4201999,CDM,270,RC,,,OUTPATIENT,,,17.74,10.644,,15.08,85,,12.064,Percent of total billed charges,85% of total billed charges,8.87,50,,7.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.87,50,,7.096,percent of total billed charges,50% of total billed charges,5.67,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,5.67,31.95,,4.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.74,38,,81.168,percent of total billed charges,38% of total billed charges,7.1,40,,5.68,percent of total billed charges,40% of total billed charges,4339.94,5991,
ACTICOAT DRESSING 4X4,4202000,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,123.424,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4340.94,5992,
SUTURE 2.0 CHROMIC GS11,4202001,CDM,270,RC,,,OUTPATIENT,,,14.05,8.43,,11.94,85,,9.552,Percent of total billed charges,85% of total billed charges,7.03,50,,5.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.03,50,,5.624,percent of total billed charges,50% of total billed charges,4.49,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,4.49,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.34,38,,128.288,percent of total billed charges,38% of total billed charges,5.62,40,,4.496,percent of total billed charges,40% of total billed charges,4341.94,5993,
SUTURE 4.0 SURGIGUT PLN V-20,4202002,CDM,270,RC,,,OUTPATIENT,,,12.66,7.596,,10.76,85,,8.608,Percent of total billed charges,85% of total billed charges,6.33,50,,5.064,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.33,50,,5.064,percent of total billed charges,50% of total billed charges,4.04,31.95,,3.232,percent of total billed charges,31.95% of total billed charges,4.04,31.95,,3.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.81,38,,383.952,percent of total billed charges,38% of total billed charges,5.06,40,,4.048,percent of total billed charges,40% of total billed charges,4342.94,5994,
SUTURE 3.0 VICRYL CV25,4202007,CDM,270,RC,,,OUTPATIENT,,,37.57,22.542,,31.93,85,,25.544,Percent of total billed charges,85% of total billed charges,18.79,50,,15.032,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.79,50,,15.032,percent of total billed charges,50% of total billed charges,12,31.95,,9.6,percent of total billed charges,31.95% of total billed charges,12,31.95,,9.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.28,38,,135.888,percent of total billed charges,38% of total billed charges,15.03,40,,12.024,percent of total billed charges,40% of total billed charges,4343.94,5995,
PUNCH BIOPSY 4MM DISPOSABLE,4202025,CDM,270,RC,,,OUTPATIENT,,,14.41,8.646,,12.25,85,,9.8,Percent of total billed charges,85% of total billed charges,7.21,50,,5.768,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.21,50,,5.768,percent of total billed charges,50% of total billed charges,4.6,31.95,,3.68,percent of total billed charges,31.95% of total billed charges,4.6,31.95,,3.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.48,38,,1228.16,percent of total billed charges,38% of total billed charges,5.76,40,,4.608,percent of total billed charges,40% of total billed charges,4344.94,5996,
LARYNGEAL MASK AIRWAY SIZE #5,4202026,CDM,270,RC,,,OUTPATIENT,,,7.34,4.404,,6.24,85,,4.992,Percent of total billed charges,85% of total billed charges,3.67,50,,2.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.67,50,,2.936,percent of total billed charges,50% of total billed charges,2.35,31.95,,1.88,percent of total billed charges,31.95% of total billed charges,2.35,31.95,,1.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.79,38,,108.224,percent of total billed charges,38% of total billed charges,2.94,40,,2.352,percent of total billed charges,40% of total billed charges,4345.94,5997,
SUTURE 1.0 VICRYL 1 GS-24,4202027,CDM,270,RC,A4649,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,31.64,35.15,,25.312,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,93.632,percent of total billed charges,38% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,4346.94,5998,
MESH SURGICAL VICRYL KNITTED,4202031,CDM,270,RC,,,OUTPATIENT,,,1233.33,739.998,,1048.33,85,,838.664,Percent of total billed charges,85% of total billed charges,616.67,50,,493.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,616.67,50,,493.336,percent of total billed charges,50% of total billed charges,394.05,31.95,,315.24,percent of total billed charges,31.95% of total billed charges,394.05,31.95,,315.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,468.67,38,,93.632,percent of total billed charges,38% of total billed charges,493.33,40,,394.664,percent of total billed charges,40% of total billed charges,4347.94,5999,
JELCO 18GX1.25'''' IV CATHETER,4202032,CDM,270,RC,,,OUTPATIENT,,,1.42,0.852,,1.21,85,,0.968,Percent of total billed charges,85% of total billed charges,0.71,50,,0.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.71,50,,0.568,percent of total billed charges,50% of total billed charges,0.45,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,0.45,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.54,38,,93.632,percent of total billed charges,38% of total billed charges,0.57,40,,0.456,percent of total billed charges,40% of total billed charges,4348.94,6000,
JELCO 20GX1.25'''' IV CATHETER,4202033,CDM,270,RC,,,OUTPATIENT,,,1.42,0.852,,1.21,85,,0.968,Percent of total billed charges,85% of total billed charges,0.71,50,,0.568,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.71,50,,0.568,percent of total billed charges,50% of total billed charges,0.45,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,0.45,31.95,,0.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.54,38,,93.632,percent of total billed charges,38% of total billed charges,0.57,40,,0.456,percent of total billed charges,40% of total billed charges,4349.94,6001,
SORBAFIX ABSORBABLE FIXATION SYSTEM,4202034,CDM,270,RC,,,OUTPATIENT,,,1000,600,,850,85,,680,Percent of total billed charges,85% of total billed charges,500,50,,400,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,500,50,,400,percent of total billed charges,50% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,93.632,percent of total billed charges,38% of total billed charges,400,40,,320,percent of total billed charges,40% of total billed charges,4350.94,6002,
CUTTING LOOP 27FR,4202035,CDM,270,RC,,,OUTPATIENT,,,103.12,61.872,,87.65,85,,70.12,Percent of total billed charges,85% of total billed charges,51.56,50,,41.248,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,51.56,50,,41.248,percent of total billed charges,50% of total billed charges,32.95,31.95,,26.36,percent of total billed charges,31.95% of total billed charges,32.95,31.95,,26.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.19,38,,93.632,percent of total billed charges,38% of total billed charges,41.25,40,,33,percent of total billed charges,40% of total billed charges,4351.94,6003,
SUTURE CV-0 GORTEX,4202036,CDM,270,RC,,,OUTPATIENT,,,21.67,13.002,,18.42,85,,14.736,Percent of total billed charges,85% of total billed charges,10.84,50,,8.672,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.84,50,,8.672,percent of total billed charges,50% of total billed charges,6.92,31.95,,5.536,percent of total billed charges,31.95% of total billed charges,6.92,31.95,,5.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.23,38,,93.632,percent of total billed charges,38% of total billed charges,8.67,40,,6.936,percent of total billed charges,40% of total billed charges,4352.94,6004,
WOUND RETRACTOR X-SMALL 2CM,4202041,CDM,270,RC,,,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.58,38,,40.128,percent of total billed charges,38% of total billed charges,16.4,40,,13.12,percent of total billed charges,40% of total billed charges,4353.94,6005,
WOUND RETRACTOR MEDIUM 5-9CM,4202043,CDM,270,RC,,,OUTPATIENT,,,41,24.6,,34.85,85,,27.88,Percent of total billed charges,85% of total billed charges,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.5,50,,16.4,percent of total billed charges,50% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.58,38,,11.856,percent of total billed charges,38% of total billed charges,16.4,40,,13.12,percent of total billed charges,40% of total billed charges,4354.94,6006,
PUNCH BIOPSY 5MM DISPOSABLE,4202052,CDM,270,RC,,,OUTPATIENT,,,14.38,8.628,,12.22,85,,9.776,Percent of total billed charges,85% of total billed charges,7.19,50,,5.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.19,50,,5.752,percent of total billed charges,50% of total billed charges,4.59,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,4.59,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.46,38,,11.552,percent of total billed charges,38% of total billed charges,5.75,40,,4.6,percent of total billed charges,40% of total billed charges,4355.94,6007,
PUNCH BIOPSY 6MM DISPOSABLE,4202053,CDM,270,RC,,,OUTPATIENT,,,14.38,8.628,,12.22,85,,9.776,Percent of total billed charges,85% of total billed charges,7.19,50,,5.752,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.19,50,,5.752,percent of total billed charges,50% of total billed charges,4.59,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,4.59,31.95,,3.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.46,38,,279.072,percent of total billed charges,38% of total billed charges,5.75,40,,4.6,percent of total billed charges,40% of total billed charges,4356.94,6008,
SUTURE 4.0 MONOSOFT P-12,4202058,CDM,270,RC,,,OUTPATIENT,,,16.18,9.708,,13.75,85,,11,Percent of total billed charges,85% of total billed charges,8.09,50,,6.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.09,50,,6.472,percent of total billed charges,50% of total billed charges,5.17,31.95,,4.136,percent of total billed charges,31.95% of total billed charges,5.17,31.95,,4.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.15,38,,124.944,percent of total billed charges,38% of total billed charges,6.47,40,,5.176,percent of total billed charges,40% of total billed charges,4357.94,6009,
SUTURE 0.0 ETHIBOND GREEN V34 KV34,4202059,CDM,270,RC,,,OUTPATIENT,,,12.64,7.584,,10.74,85,,8.592,Percent of total billed charges,85% of total billed charges,6.32,50,,5.056,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.32,50,,5.056,percent of total billed charges,50% of total billed charges,4.04,31.95,,3.232,percent of total billed charges,31.95% of total billed charges,4.04,31.95,,3.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.8,38,,854.848,percent of total billed charges,38% of total billed charges,5.06,40,,4.048,percent of total billed charges,40% of total billed charges,4358.94,6010,
"SUTURE 2.0 PROLENE CT1, GS21",4202061,CDM,270,RC,,,OUTPATIENT,,,13.33,7.998,,11.33,85,,9.064,Percent of total billed charges,85% of total billed charges,6.67,50,,5.336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.67,50,,5.336,percent of total billed charges,50% of total billed charges,4.26,31.95,,3.408,percent of total billed charges,31.95% of total billed charges,4.26,31.95,,3.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.07,38,,105.792,percent of total billed charges,38% of total billed charges,5.33,40,,4.264,percent of total billed charges,40% of total billed charges,4359.94,6011,
SUTURE 4.0 POLYSORB PS-4 P24,4202064,CDM,270,RC,,,OUTPATIENT,,,17.37,10.422,,14.76,85,,11.808,Percent of total billed charges,85% of total billed charges,8.69,50,,6.952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.69,50,,6.952,percent of total billed charges,50% of total billed charges,5.55,31.95,,4.44,percent of total billed charges,31.95% of total billed charges,5.55,31.95,,4.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.6,38,,124.944,percent of total billed charges,38% of total billed charges,6.95,40,,5.56,percent of total billed charges,40% of total billed charges,4360.94,6012,
SUTURE 3.0 MONOSOFT PS-3 P-11,4202065,CDM,270,RC,,,OUTPATIENT,,,20.46,12.276,,17.39,85,,13.912,Percent of total billed charges,85% of total billed charges,10.23,50,,8.184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.23,50,,8.184,percent of total billed charges,50% of total billed charges,6.54,31.95,,5.232,percent of total billed charges,31.95% of total billed charges,6.54,31.95,,5.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.77,38,,105.792,percent of total billed charges,38% of total billed charges,8.18,40,,6.544,percent of total billed charges,40% of total billed charges,4361.94,6013,
PICC LINE 5FR 55CM POWER SOLO CATH KIT,4202066,CDM,270,RC,,,OUTPATIENT,,,1100,660,,935,85,,748,Percent of total billed charges,85% of total billed charges,550,50,,440,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,550,50,,440,percent of total billed charges,50% of total billed charges,351.45,31.95,,281.16,percent of total billed charges,31.95% of total billed charges,351.45,31.95,,281.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,418,38,,105.792,percent of total billed charges,38% of total billed charges,440,40,,352,percent of total billed charges,40% of total billed charges,4362.94,6014,
ADAPTER (MDI) METERED DOSE INHALER,4202067,CDM,270,RC,,,OUTPATIENT,,,2.88,1.728,,2.45,85,,1.96,Percent of total billed charges,85% of total billed charges,1.44,50,,1.152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.44,50,,1.152,percent of total billed charges,50% of total billed charges,0.92,31.95,,0.736,percent of total billed charges,31.95% of total billed charges,0.92,31.95,,0.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.09,38,,994.384,percent of total billed charges,38% of total billed charges,1.15,40,,0.92,percent of total billed charges,40% of total billed charges,4363.94,6015,
IRRIGATOR IGLO WOUND SHIELD,4202076,CDM,270,RC,,,OUTPATIENT,,,4.05,2.43,,3.44,85,,2.752,Percent of total billed charges,85% of total billed charges,2.03,50,,1.624,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.03,50,,1.624,percent of total billed charges,50% of total billed charges,1.29,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,1.29,31.95,,1.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.54,38,,20.672,percent of total billed charges,38% of total billed charges,1.62,40,,1.296,percent of total billed charges,40% of total billed charges,4364.94,6016,
THORACIC CATHETER 36FR,4202077,CDM,270,RC,,,OUTPATIENT,,,11.76,7.056,,10,85,,8,Percent of total billed charges,85% of total billed charges,5.88,50,,4.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.88,50,,4.704,percent of total billed charges,50% of total billed charges,3.76,31.95,,3.008,percent of total billed charges,31.95% of total billed charges,3.76,31.95,,3.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.47,38,,781.28,percent of total billed charges,38% of total billed charges,4.7,40,,3.76,percent of total billed charges,40% of total billed charges,4365.94,6017,
CLIP ENDO PISTOL GRIP L APPLICATOR,4202078,CDM,270,RC,,,OUTPATIENT,,,285,171,,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,142.5,50,,114,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,142.5,50,,114,percent of total billed charges,50% of total billed charges,91.06,31.95,,72.848,percent of total billed charges,31.95% of total billed charges,91.06,31.95,,72.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,108.3,38,,648.128,percent of total billed charges,38% of total billed charges,114,40,,91.2,percent of total billed charges,40% of total billed charges,4366.94,6018,
PEAK FLOW METER,4202079,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,44.992,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4367.94,6019,
CAUTERY TIP POLISHER PAD,4202080,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,14.896,percent of total billed charges,38% of total billed charges,0.8,40,,0.64,percent of total billed charges,40% of total billed charges,4368.94,6020,
RETRIEVER UNIVERSAL ROTH NET PLANTIUM,4202081,CDM,270,RC,,,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,150,50,,120,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,150,50,,120,percent of total billed charges,50% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,764.256,percent of total billed charges,38% of total billed charges,120,40,,96,percent of total billed charges,40% of total billed charges,4369.94,6021,
DEVICE SUTURING 10MM ENDO STITCH,4202082,CDM,270,RC,,,OUTPATIENT,,,1190,714,,1011.5,85,,809.2,Percent of total billed charges,85% of total billed charges,595,50,,476,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,595,50,,476,percent of total billed charges,50% of total billed charges,380.21,31.95,,304.168,percent of total billed charges,31.95% of total billed charges,380.21,31.95,,304.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,452.2,38,,20.672,percent of total billed charges,38% of total billed charges,476,40,,380.8,percent of total billed charges,40% of total billed charges,4370.94,6022,
HARMONIC CURVED SHEAR ENDO,4202084,CDM,270,RC,,,OUTPATIENT,,,1850,1110,,1572.5,85,,1258,Percent of total billed charges,85% of total billed charges,925,50,,740,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,925,50,,740,percent of total billed charges,50% of total billed charges,591.08,31.95,,472.864,percent of total billed charges,31.95% of total billed charges,591.08,31.95,,472.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,703,38,,133.152,percent of total billed charges,38% of total billed charges,740,40,,592,percent of total billed charges,40% of total billed charges,4371.94,6023,
HARMONIC ACE CURVED SHEAR,4202085,CDM,270,RC,,,OUTPATIENT,,,1540,924,,1309,85,,1047.2,Percent of total billed charges,85% of total billed charges,770,50,,616,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,770,50,,616,percent of total billed charges,50% of total billed charges,492.03,31.95,,393.624,percent of total billed charges,31.95% of total billed charges,492.03,31.95,,393.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,585.2,38,,43.168,percent of total billed charges,38% of total billed charges,616,40,,492.8,percent of total billed charges,40% of total billed charges,4372.94,6024,
TROCAR BLADELESS TIP 12MM 100MM W/HANDLE,4202086,CDM,270,RC,,,OUTPATIENT,,,333,199.8,,283.05,85,,226.44,Percent of total billed charges,85% of total billed charges,166.5,50,,133.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,166.5,50,,133.2,percent of total billed charges,50% of total billed charges,106.39,31.95,,85.112,percent of total billed charges,31.95% of total billed charges,106.39,31.95,,85.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.54,38,,37.696,percent of total billed charges,38% of total billed charges,133.2,40,,106.56,percent of total billed charges,40% of total billed charges,4373.94,6025,
VASCULAR GRAFTS BIFURCATE 22X11,4202088,CDM,270,RC,,,OUTPATIENT,,,1610,966,,1368.5,85,,1094.8,Percent of total billed charges,85% of total billed charges,805,50,,644,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,805,50,,644,percent of total billed charges,50% of total billed charges,514.4,31.95,,411.52,percent of total billed charges,31.95% of total billed charges,514.4,31.95,,411.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,611.8,38,,266.912,percent of total billed charges,38% of total billed charges,644,40,,515.2,percent of total billed charges,40% of total billed charges,4374.94,6026,
TIES SOFSILK 1.0,4202089,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,228.608,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4375.94,6027,
MEDIPORE DRESSING WOUND SOFT CLOTH,4202090,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,35.264,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4376.94,6028,
OPTILOC DRESSING 4X4 FORMALLY ENLUXTRA,4202092,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,97.584,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4377.94,6029,
OPTILOC DRESSING 6.5X10 FORMALLY ENLUXTRA,4202093,CDM,270,RC,,,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.5,50,,22,percent of total billed charges,50% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.9,38,,397.024,percent of total billed charges,38% of total billed charges,22,40,,17.6,percent of total billed charges,40% of total billed charges,4378.94,6030,
SUTURE 2.0 PROLENE C-2,4202095,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,1119.328,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4379.94,6031,
OPTILOC DRESSING 3X3 FORMALLY ENLUXTRA,4202100,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,114.304,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4380.94,6032,
TIE 0.0 POLYSORB 3X30,4202101,CDM,270,RC,,,OUTPATIENT,,,14.08,8.448,,11.97,85,,9.576,Percent of total billed charges,85% of total billed charges,7.04,50,,5.632,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.04,50,,5.632,percent of total billed charges,50% of total billed charges,4.5,31.95,,3.6,percent of total billed charges,31.95% of total billed charges,4.5,31.95,,3.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.35,38,,105.792,percent of total billed charges,38% of total billed charges,5.63,40,,4.504,percent of total billed charges,40% of total billed charges,4381.94,6033,
SUTURE 0.0 SOFTSILK V20,4202102,CDM,270,RC,,,OUTPATIENT,,,9.47,5.682,,8.05,85,,6.44,Percent of total billed charges,85% of total billed charges,4.74,50,,3.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.74,50,,3.792,percent of total billed charges,50% of total billed charges,3.03,31.95,,2.424,percent of total billed charges,31.95% of total billed charges,3.03,31.95,,2.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.6,38,,105.792,percent of total billed charges,38% of total billed charges,3.79,40,,3.032,percent of total billed charges,40% of total billed charges,4382.94,6034,
SUTURE 2.0 SOFTSILK V20,4202103,CDM,270,RC,,,OUTPATIENT,,,8.13,4.878,,6.91,85,,5.528,Percent of total billed charges,85% of total billed charges,4.07,50,,3.256,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.07,50,,3.256,percent of total billed charges,50% of total billed charges,2.6,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,2.6,31.95,,2.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.09,38,,1176.48,percent of total billed charges,38% of total billed charges,3.25,40,,2.6,percent of total billed charges,40% of total billed charges,4383.94,6035,
SUTURE 3.0 POLYSORB GS-21,4202105,CDM,270,RC,,,OUTPATIENT,,,10.65,6.39,,9.05,85,,7.24,Percent of total billed charges,85% of total billed charges,5.33,50,,4.264,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.33,50,,4.264,percent of total billed charges,50% of total billed charges,3.4,31.95,,2.72,percent of total billed charges,31.95% of total billed charges,3.4,31.95,,2.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.05,38,,154.128,percent of total billed charges,38% of total billed charges,4.26,40,,3.408,percent of total billed charges,40% of total billed charges,4384.94,6036,
TIE 3.0 POLYSORB,4202106,CDM,270,RC,,,OUTPATIENT,,,36.3,21.78,,30.86,85,,24.688,Percent of total billed charges,85% of total billed charges,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.15,50,,14.52,percent of total billed charges,50% of total billed charges,11.6,31.95,,9.28,percent of total billed charges,31.95% of total billed charges,11.6,31.95,,9.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.79,38,,151.696,percent of total billed charges,38% of total billed charges,14.52,40,,11.616,percent of total billed charges,40% of total billed charges,4385.94,6037,
SUTURE 0.0 SURGIPRO GS-25,4202108,CDM,270,RC,,,OUTPATIENT,,,13.48,8.088,,11.46,85,,9.168,Percent of total billed charges,85% of total billed charges,6.74,50,,5.392,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.74,50,,5.392,percent of total billed charges,50% of total billed charges,4.31,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.12,38,,20.976,percent of total billed charges,38% of total billed charges,5.39,40,,4.312,percent of total billed charges,40% of total billed charges,4386.94,6038,
VISCERA RETAINER LARGE,4202112,CDM,270,RC,,,OUTPATIENT,,,96,57.6,,81.6,85,,65.28,Percent of total billed charges,85% of total billed charges,48,50,,38.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48,50,,38.4,percent of total billed charges,50% of total billed charges,30.67,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,30.67,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.48,38,,20.976,percent of total billed charges,38% of total billed charges,38.4,40,,30.72,percent of total billed charges,40% of total billed charges,4387.94,6039,
SUTURE 6.0 SOFTSILK P-12,4202114,CDM,270,RC,,,OUTPATIENT,,,15.73,9.438,,13.37,85,,10.696,Percent of total billed charges,85% of total billed charges,7.87,50,,6.296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.87,50,,6.296,percent of total billed charges,50% of total billed charges,5.03,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,5.03,31.95,,4.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.98,38,,20.976,percent of total billed charges,38% of total billed charges,6.29,40,,5.032,percent of total billed charges,40% of total billed charges,4388.94,6040,
SUTURE 5.0 MONOSOF PC-5 PC-12,4202115,CDM,270,RC,,,OUTPATIENT,,,21.69,13.014,,18.44,85,,14.752,Percent of total billed charges,85% of total billed charges,10.85,50,,8.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.85,50,,8.68,percent of total billed charges,50% of total billed charges,6.93,31.95,,5.544,percent of total billed charges,31.95% of total billed charges,6.93,31.95,,5.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.24,38,,88.768,percent of total billed charges,38% of total billed charges,8.68,40,,6.944,percent of total billed charges,40% of total billed charges,4389.94,6041,
SUTURE 4.0 CHROMIC GUT P-13,4202117,CDM,270,RC,,,OUTPATIENT,,,25.06,15.036,,21.3,85,,17.04,Percent of total billed charges,85% of total billed charges,12.53,50,,10.024,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.53,50,,10.024,percent of total billed charges,50% of total billed charges,8.01,31.95,,6.408,percent of total billed charges,31.95% of total billed charges,8.01,31.95,,6.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.52,38,,501.6,percent of total billed charges,38% of total billed charges,10.02,40,,8.016,percent of total billed charges,40% of total billed charges,4390.94,6042,
PLUG PERFIX LARGE 1.6''''X1.9'''',4202118,CDM,270,RC,,,OUTPATIENT,,,800,480,,680,85,,544,Percent of total billed charges,85% of total billed charges,400,50,,320,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,400,50,,320,percent of total billed charges,50% of total billed charges,255.6,31.95,,204.48,percent of total billed charges,31.95% of total billed charges,255.6,31.95,,204.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,304,38,,2287.6,percent of total billed charges,38% of total billed charges,320,40,,256,percent of total billed charges,40% of total billed charges,4391.94,6043,
SUTURE 6.0 MONOSOFT C1,4202119,CDM,270,RC,,,OUTPATIENT,,,6.15,3.69,,5.23,85,,4.184,Percent of total billed charges,85% of total billed charges,3.08,50,,2.464,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.08,50,,2.464,percent of total billed charges,50% of total billed charges,1.96,31.95,,1.568,percent of total billed charges,31.95% of total billed charges,1.96,31.95,,1.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.34,38,,228,percent of total billed charges,38% of total billed charges,2.46,40,,1.968,percent of total billed charges,40% of total billed charges,4392.94,6044,
TAPE HYPAFIX DRESSING 2''''X10YDS,4202122,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,1634,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4393.94,6045,
DRESSING TENDERWET 3X3'''' ACTIVE CAVITY,4202123,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,73.568,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4394.94,6046,
TROCAR BLADELESS 150CM,4202124,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,73.568,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4395.94,6047,
FOAM BANDAGE 4X4 (OPTIFOAM) ADH,4202126,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,592.8,percent of total billed charges,38% of total billed charges,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,4396.94,6048,
GEL ANTIMICROBIAL SILVASORB SILVER 1.5 OZ,4202129,CDM,270,RC,,,OUTPATIENT,,,59,35.4,,50.15,85,,40.12,Percent of total billed charges,85% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,18.85,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,18.85,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.42,38,,114,percent of total billed charges,38% of total billed charges,23.6,40,,18.88,percent of total billed charges,40% of total billed charges,4397.94,6049,
BRAVO CF CAPSULE,4202130,CDM,270,RC,,,OUTPATIENT,,,597,358.2,,507.45,85,,405.96,Percent of total billed charges,85% of total billed charges,298.5,50,,238.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,298.5,50,,238.8,percent of total billed charges,50% of total billed charges,190.74,31.95,,152.592,percent of total billed charges,31.95% of total billed charges,190.74,31.95,,152.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,226.86,38,,820.8,percent of total billed charges,38% of total billed charges,238.8,40,,191.04,percent of total billed charges,40% of total billed charges,4398.94,6050,
SCD KNEE MEDIUM,4202133,CDM,270,RC,,,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40,50,,32,percent of total billed charges,50% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.4,38,,410.4,percent of total billed charges,38% of total billed charges,32,40,,25.6,percent of total billed charges,40% of total billed charges,4399.94,6051,
LARYNGEAL MASK AIRWAY SIZE #3,4202134,CDM,270,RC,,,OUTPATIENT,,,16.69,10.014,,14.19,85,,11.352,Percent of total billed charges,85% of total billed charges,8.35,50,,6.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.35,50,,6.68,percent of total billed charges,50% of total billed charges,5.33,31.95,,4.264,percent of total billed charges,31.95% of total billed charges,5.33,31.95,,4.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.34,38,,51.072,percent of total billed charges,38% of total billed charges,6.68,40,,5.344,percent of total billed charges,40% of total billed charges,4400.94,6052,
EZ STABLIZER,4202135,CDM,270,RC,,,OUTPATIENT,,,16.76,10.056,,14.25,85,,11.4,Percent of total billed charges,85% of total billed charges,8.38,50,,6.704,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.38,50,,6.704,percent of total billed charges,50% of total billed charges,5.35,31.95,,4.28,percent of total billed charges,31.95% of total billed charges,5.35,31.95,,4.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.37,38,,1816.4,percent of total billed charges,38% of total billed charges,6.7,40,,5.36,percent of total billed charges,40% of total billed charges,4401.94,6053,
MAGNEVIST 20ML VIALS FOR MRI,4202138,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,228,percent of total billed charges,38% of total billed charges,5.6,40,,4.48,percent of total billed charges,40% of total billed charges,4402.94,6054,
FMC MAGNEVIST 20 ML,4202138,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,1301.12,percent of total billed charges,38% of total billed charges,5.6,40,,4.48,percent of total billed charges,40% of total billed charges,4403.94,6055,
DISPOSABLE SCISSOR,4202139,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,83.6,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4404.94,6056,
ISOLATION GOWN,4202140,CDM,271,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,120.08,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,4405.94,6057,
LEMON GLY SWABS PK,4202146,CDM,271,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,136.8,percent of total billed charges,38% of total billed charges,0.4,40,,0.32,percent of total billed charges,40% of total billed charges,4406.94,6058,
LIGASURE IMPACT,4202166,CDM,271,RC,,,OUTPATIENT,,,668.85,401.31,,568.52,85,,454.816,Percent of total billed charges,85% of total billed charges,334.43,50,,267.544,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,334.43,50,,267.544,percent of total billed charges,50% of total billed charges,213.7,31.95,,170.96,percent of total billed charges,31.95% of total billed charges,213.7,31.95,,170.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,254.16,38,,27.36,percent of total billed charges,38% of total billed charges,267.54,40,,214.032,percent of total billed charges,40% of total billed charges,4407.94,6059,
SEALER DIVIDER 5MM LIGASURE,4202167,CDM,271,RC,,,OUTPATIENT,,,802.62,481.572,,682.23,85,,545.784,Percent of total billed charges,85% of total billed charges,401.31,50,,321.048,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,401.31,50,,321.048,percent of total billed charges,50% of total billed charges,256.44,31.95,,205.152,percent of total billed charges,31.95% of total billed charges,256.44,31.95,,205.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,305,38,,905.92,percent of total billed charges,38% of total billed charges,321.05,40,,256.84,percent of total billed charges,40% of total billed charges,4408.94,6060,
LACERATION TRAY LATEX FREE,4202168,CDM,271,RC,,,OUTPATIENT,,,3.94,2.364,,3.35,85,,2.68,Percent of total billed charges,85% of total billed charges,1.97,50,,1.576,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.97,50,,1.576,percent of total billed charges,50% of total billed charges,1.26,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,1.26,31.95,,1.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.5,38,,20.976,percent of total billed charges,38% of total billed charges,1.58,40,,1.264,percent of total billed charges,40% of total billed charges,4409.94,6061,
MESH 8X12'''' RECTANGLE PROCEED,4202173,CDM,271,RC,,,OUTPATIENT,,,2584.57,1550.742,,2196.88,85,,1757.504,Percent of total billed charges,85% of total billed charges,1292.29,50,,1033.832,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1292.29,50,,1033.832,percent of total billed charges,50% of total billed charges,825.77,31.95,,660.616,percent of total billed charges,31.95% of total billed charges,825.77,31.95,,660.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,982.14,38,,20.976,percent of total billed charges,38% of total billed charges,1033.83,40,,827.064,percent of total billed charges,40% of total billed charges,4410.94,6062,
INCISION/DRAIN TRAY,4202174,CDM,272,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,2.808,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,2.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,93.632,percent of total billed charges,38% of total billed charges,4.4,40,,3.52,percent of total billed charges,40% of total billed charges,4411.94,6063,
DISPOSABLE BIOPSY FORCEP,4202183,CDM,272,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,93.632,percent of total billed charges,38% of total billed charges,18.4,40,,14.72,percent of total billed charges,40% of total billed charges,4412.94,6064,
DISPOSABLE HOT BIOPSY FORCEPT,4202184,CDM,272,RC,A4649,HCPCS,OUTPATIENT,,,58.6,35.16,,49.81,85,,39.848,Percent of total billed charges,85% of total billed charges,29.3,50,,23.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.3,50,,23.44,percent of total billed charges,50% of total billed charges,20.6,35.15,,16.48,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.27,38,,93.632,percent of total billed charges,38% of total billed charges,18.72,31.95,,14.976,percent of total billed charges,31.95% of total billed charges,4413.94,6065,
DISPOSABLE ELECTROSURGICAL SNARE 25MM,4202187,CDM,272,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,93.632,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,4414.94,6066,
TAB IMMUNIZATION DARK BLUE,4202188,CDM,272,RC,,,OUTPATIENT,,,121,72.6,,102.85,85,,82.28,Percent of total billed charges,85% of total billed charges,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,60.5,50,,48.4,percent of total billed charges,50% of total billed charges,38.66,31.95,,30.928,percent of total billed charges,31.95% of total billed charges,38.66,31.95,,30.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.98,38,,93.632,percent of total billed charges,38% of total billed charges,48.4,40,,38.72,percent of total billed charges,40% of total billed charges,4415.94,6067,
ULTRAPRO MESH 7.5X15CM,4202192,CDM,272,RC,C1781,HCPCS,OUTPATIENT,,,585,351,,497.25,85,,397.8,Percent of total billed charges,85% of total billed charges,292.5,50,,234,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,292.5,50,,234,percent of total billed charges,50% of total billed charges,205.63,35.15,,164.504,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,222.3,38,,93.632,percent of total billed charges,38% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,4416.94,6068,
COAPTITE INJECTABLE IMPLANT 1ML SYRINGE,4202194,CDM,272,RC,L8603,HCPCS,OUTPATIENT,,,396.9,238.14,,337.37,85,,269.896,Percent of total billed charges,85% of total billed charges,198.45,50,,158.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,198.45,50,,158.76,percent of total billed charges,50% of total billed charges,139.51,35.15,,111.608,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,513.26,100,,,fee schedule,100% of CMS custom fee schedule,150.82,38,,93.632,percent of total billed charges,38% of total billed charges,126.81,31.95,,101.448,percent of total billed charges,31.95% of total billed charges,4417.94,6069,
HELICAL STONE EXTRACTOR 3 WIRE 2.8,4202195,CDM,272,RC,,,OUTPATIENT,,,384,230.4,,326.4,85,,261.12,Percent of total billed charges,85% of total billed charges,192,50,,153.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,192,50,,153.6,percent of total billed charges,50% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,501.6,percent of total billed charges,38% of total billed charges,153.6,40,,122.88,percent of total billed charges,40% of total billed charges,4418.94,6070,
DERMA+FLEXQS SKIN ADHESIVE,4202196,CDM,272,RC,A4649,HCPCS,OUTPATIENT,,,63,37.8,,53.55,85,,42.84,Percent of total billed charges,85% of total billed charges,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31.5,50,,25.2,percent of total billed charges,50% of total billed charges,22.14,35.15,,17.712,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.94,38,,296.096,percent of total billed charges,38% of total billed charges,20.13,31.95,,16.104,percent of total billed charges,31.95% of total billed charges,4419.94,6071,
KLING 4,4202214,CDM,272,RC,A4649,HCPCS,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.76,35.15,,1.408,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,150.784,percent of total billed charges,38% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,4420.94,6072,
KLING 6'''',4202215,CDM,272,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,547.2,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4421.94,6073,
STERI STRIP 1/4,4202224,CDM,272,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,592.8,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4422.94,6074,
SHILEY TRACH CUFFED 4PDC,4202257,CDM,272,RC,A7520,HCPCS,OUTPATIENT,,,129,77.4,,109.65,85,,87.72,Percent of total billed charges,85% of total billed charges,64.5,50,,51.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,64.5,50,,51.6,percent of total billed charges,50% of total billed charges,45.34,35.15,,36.272,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,64.78,100,,,fee schedule,100% of CMS custom fee schedule,49.02,38,,592.8,percent of total billed charges,38% of total billed charges,41.22,31.95,,32.976,percent of total billed charges,31.95% of total billed charges,4423.94,6075,
SHILEY TRACH UNCUFFED 6CFN,4202259,CDM,272,RC,A7520,HCPCS,OUTPATIENT,,,173,103.8,,147.05,85,,117.64,Percent of total billed charges,85% of total billed charges,86.5,50,,69.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,86.5,50,,69.2,percent of total billed charges,50% of total billed charges,60.81,35.15,,48.648,percent of total billed charges,35.15% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,64.78,100,,,fee schedule,100% of CMS custom fee schedule,65.74,38,,661.2,percent of total billed charges,38% of total billed charges,55.27,31.95,,44.216,percent of total billed charges,31.95% of total billed charges,4424.94,6076,
SHILEY TRACH CUFFED 8CFS,4202260,CDM,272,RC,A7520,HCPCS,OUTPATIENT,,,139,83.4,,118.15,85,,94.52,Percent of total billed charges,85% of total billed charges,69.5,50,,55.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,69.5,50,,55.6,percent of total billed charges,50% of total billed charges,48.86,35.15,,39.088,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,64.78,100,,,fee schedule,100% of CMS custom fee schedule,52.82,38,,1687.2,percent of total billed charges,38% of total billed charges,44.41,31.95,,35.528,percent of total billed charges,31.95% of total billed charges,4425.94,6077,
SHILEY TRACH CUFFED 10LPC,4202261,CDM,272,RC,A7520,HCPCS,OUTPATIENT,,,141,84.6,,119.85,85,,95.88,Percent of total billed charges,85% of total billed charges,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,70.5,50,,56.4,percent of total billed charges,50% of total billed charges,49.56,35.15,,39.648,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,64.78,100,,,fee schedule,100% of CMS custom fee schedule,53.58,38,,60.8,percent of total billed charges,38% of total billed charges,45.05,31.95,,36.04,percent of total billed charges,31.95% of total billed charges,4426.94,6078,
BALLOON DILATORS CRE,4202268,CDM,272,RC,,,OUTPATIENT,,,247.5,148.5,,210.38,85,,168.304,Percent of total billed charges,85% of total billed charges,123.75,50,,99,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,123.75,50,,99,percent of total billed charges,50% of total billed charges,79.08,31.95,,63.264,percent of total billed charges,31.95% of total billed charges,79.08,31.95,,63.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,94.05,38,,378.48,percent of total billed charges,38% of total billed charges,99,40,,79.2,percent of total billed charges,40% of total billed charges,4427.94,6079,
ET TUBE  9.5 CUFFED,4202270,CDM,272,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,129.2,percent of total billed charges,38% of total billed charges,5.4,40,,4.32,percent of total billed charges,40% of total billed charges,4428.94,6080,
PATCH CRURASOFT 2.8''''X2.4'''',4202279,CDM,272,RC,,,OUTPATIENT,,,1254,752.4,,1065.9,85,,852.72,Percent of total billed charges,85% of total billed charges,627,50,,501.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,627,50,,501.6,percent of total billed charges,50% of total billed charges,400.65,31.95,,320.52,percent of total billed charges,31.95% of total billed charges,400.65,31.95,,320.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,476.52,38,,1202.32,percent of total billed charges,38% of total billed charges,501.6,40,,401.28,percent of total billed charges,40% of total billed charges,4429.94,6081,
FMC 9% SC 100CC,4202282,CDM,272,RC,A4216,HCPCS,OUTPATIENT,,,18.56,11.136,,15.78,85,,12.624,Percent of total billed charges,85% of total billed charges,0.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,6.52,35.15,,5.216,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,0.61,100,,,fee schedule,100% of CMS custom fee schedule,7.05,38,,93.632,percent of total billed charges,38% of total billed charges,5.93,31.95,,4.744,percent of total billed charges,31.95% of total billed charges,4430.94,6082,
FMC 9% SC 50CC,4202283,CDM,272,RC,A4216,HCPCS,OUTPATIENT,,,29.7,17.82,,25.25,85,,20.2,Percent of total billed charges,85% of total billed charges,0.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.44,35.15,,8.352,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,0.61,100,,,fee schedule,100% of CMS custom fee schedule,11.29,38,,93.632,percent of total billed charges,38% of total billed charges,9.49,31.95,,7.592,percent of total billed charges,31.95% of total billed charges,4431.94,6083,
FMC TRANSPEC SPECIMEN C,4202286,CDM,270,RC,,,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.28,38,,93.632,percent of total billed charges,38% of total billed charges,22.4,40,,17.92,percent of total billed charges,40% of total billed charges,4432.94,6084,
FMC TREADMILL,4202287,CDM,482,RC,93017,HCPCS,OUTPATIENT,,,977,586.2,,830.45,85,,664.36,Percent of total billed charges,85% of total billed charges,500.49,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,500.49,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,343.42,35.15,,,fee schedule,35.15% of LA custom fee schedule,312.15,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,371,100,,165.68,case rate,pays based on per visit rate,312.15,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,4433.94,6085,
FMC SPINAL NEEDLE 22GX7'''',4202288,CDM,270,RC,A4215,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,661.2,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,4434.94,6086,
DRESSING SILICONE 3''X4'' MEPITEL,4202335,CDM,272,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,661.2,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4435.94,6087,
SHOULDER IMMOBILIZER VELPEAU DRESSING SMALL,4202337,CDM,274,RC,A4565,HCPCS,OUTPATIENT,,,14,8.4,,14.7,105,,,case rate,pays based on 105% of threshold rate,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.92,35.15,,3.936,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,10.51,100,,,fee schedule,100% of CMS custom fee schedule,5.32,38,,1687.2,percent of total billed charges,38% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,4436.94,6088,
SHOULDER IMMOBILIZER WOMEN MED,4202338,CDM,274,RC,,,OUTPATIENT,,,32,19.2,,33.6,105,,,case rate,pays based on 105% of threshold rate,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,425.6,percent of total billed charges,38% of total billed charges,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,4437.94,6089,
SHOULDER IMMOBILIZER WOMEN XLG,4202339,CDM,274,RC,A4565,HCPCS,OUTPATIENT,,,32,19.2,,33.6,105,,,case rate,pays based on 105% of threshold rate,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,11.25,35.15,,9,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,10.51,100,,,fee schedule,100% of CMS custom fee schedule,12.16,38,,425.6,percent of total billed charges,38% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,4438.94,6090,
SHOULDER IMMOBILIZER MEN SM,4202340,CDM,274,RC,,,OUTPATIENT,,,32,19.2,,33.6,105,,,case rate,pays based on 105% of threshold rate,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,589.76,percent of total billed charges,38% of total billed charges,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,4439.94,6091,
SHOULDER IMMOBILIZER MEN MED,4202341,CDM,274,RC,,,OUTPATIENT,,,32,19.2,,33.6,105,,,case rate,pays based on 105% of threshold rate,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,592.8,percent of total billed charges,38% of total billed charges,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,4440.94,6092,
REFLUX MANAGEMENT SYSTEM SIZING TOOL,4202343,CDM,274,RC,,,OUTPATIENT,,,450,270,,472.5,105,,,case rate,pays based on 105% of threshold rate,225,50,,180,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,225,50,,180,percent of total billed charges,50% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,171,38,,1092.88,percent of total billed charges,38% of total billed charges,180,40,,144,percent of total billed charges,40% of total billed charges,4441.94,6093,
CERVICAL COLLAR FOAM MEDIUM,4202344,CDM,274,RC,L0120,HCPCS,OUTPATIENT,,,22.6,13.56,,23.73,105,,,case rate,pays based on 105% of threshold rate,11.3,50,,9.04,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.3,50,,9.04,percent of total billed charges,50% of total billed charges,7.94,35.15,,6.352,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,29.2,100,,,fee schedule,100% of CMS custom fee schedule,8.59,38,,273.6,percent of total billed charges,38% of total billed charges,7.22,31.95,,5.776,percent of total billed charges,31.95% of total billed charges,4442.94,6094,
CERVICAL COLLAR PHIL. PEDI (CHILD),4202345,CDM,274,RC,L0140,HCPCS,OUTPATIENT,,,52,31.2,,54.6,105,,,case rate,pays based on 105% of threshold rate,26,50,,20.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26,50,,20.8,percent of total billed charges,50% of total billed charges,18.28,35.15,,14.624,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,71.86,100,,,fee schedule,100% of CMS custom fee schedule,19.76,38,,993.472,percent of total billed charges,38% of total billed charges,16.61,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,4443.94,6095,
CERVICAL COLLAR PHIL.SMALL,4202355,CDM,274,RC,L0140,HCPCS,OUTPATIENT,,,42,25.2,,44.1,105,,,case rate,pays based on 105% of threshold rate,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,14.76,35.15,,11.808,percent of total billed charges,35.15% of total billed charges,139.94,31.95,,111.952,percent of total billed charges,31.95% of total billed charges,71.86,100,,,fee schedule,100% of CMS custom fee schedule,15.96,38,,993.472,percent of total billed charges,38% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,4444.94,6096,
CERVICAL COLLAR PHIL. MED,4202356,CDM,274,RC,L0140,HCPCS,OUTPATIENT,,,42,25.2,,44.1,105,,,case rate,pays based on 105% of threshold rate,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,14.76,35.15,,11.808,percent of total billed charges,35.15% of total billed charges,140.58,31.95,,112.464,percent of total billed charges,31.95% of total billed charges,71.86,100,,,fee schedule,100% of CMS custom fee schedule,15.96,38,,993.472,percent of total billed charges,38% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,4445.94,6097,
COLLES SPLINT SMALL L,4202357,CDM,274,RC,A4570,HCPCS,OUTPATIENT,,,44,26.4,,46.2,105,,,case rate,pays based on 105% of threshold rate,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,15.47,35.15,,12.376,percent of total billed charges,35.15% of total billed charges,141.54,31.95,,113.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,993.472,percent of total billed charges,38% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,4446.94,6098,
SHOULDER IMMOBILIZER VELPEAU DRESSING LARGE,4202358,CDM,274,RC,A4565,HCPCS,OUTPATIENT,,,15,9,,15.75,105,,,case rate,pays based on 105% of threshold rate,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,5.27,35.15,,4.216,percent of total billed charges,35.15% of total billed charges,141.54,31.95,,113.232,percent of total billed charges,31.95% of total billed charges,10.51,100,,,fee schedule,100% of CMS custom fee schedule,5.7,38,,868.832,percent of total billed charges,38% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4447.94,6099,
SPLINT FINGER 1 1/2'''' PADDED,4202359,CDM,274,RC,A4570,HCPCS,OUTPATIENT,,,9,5.4,,9.45,105,,,case rate,pays based on 105% of threshold rate,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,3.16,35.15,,2.528,percent of total billed charges,35.15% of total billed charges,141.54,31.95,,113.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,868.832,percent of total billed charges,38% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,4448.94,6100,
SHOULDER IMMOBILIZER VELPEAU DRESSING MEDIUM,4202360,CDM,274,RC,A4565,HCPCS,OUTPATIENT,,,15,9,,15.75,105,,,case rate,pays based on 105% of threshold rate,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,5.27,35.15,,4.216,percent of total billed charges,35.15% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,10.51,100,,,fee schedule,100% of CMS custom fee schedule,5.7,38,,90.592,percent of total billed charges,38% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4449.94,6101,
KNEE IMMOBILIZER 20,4202361,CDM,274,RC,L1830,HCPCS,OUTPATIENT,,,54,32.4,,56.7,105,,,case rate,pays based on 105% of threshold rate,27,50,,21.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27,50,,21.6,percent of total billed charges,50% of total billed charges,18.98,35.15,,15.184,percent of total billed charges,35.15% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,59.73,100,,,fee schedule,100% of CMS custom fee schedule,20.52,38,,937.84,percent of total billed charges,38% of total billed charges,17.25,31.95,,13.8,percent of total billed charges,31.95% of total billed charges,4450.94,6102,
PULSE GENERATOR EXTERNAL (PACEMAKER),4202363,CDM,275,RC,C1779,HCPCS,OUTPATIENT,,,3300,1980,,3465,105,,,case rate,pays based on 105% of threshold rate,1650,50,,1320,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1650,50,,1320,percent of total billed charges,50% of total billed charges,1159.95,35.15,,927.96,percent of total billed charges,35.15% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1254,38,,42.56,percent of total billed charges,38% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,4451.94,6103,
PUNCH 3 HOLE,4202365,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,141.3,84.78,,148.37,105,,,case rate,pays based on 105% of threshold rate,70.65,50,,56.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,70.65,50,,56.52,percent of total billed charges,50% of total billed charges,49.67,35.15,,39.736,percent of total billed charges,35.15% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.69,38,,42.56,percent of total billed charges,38% of total billed charges,45.15,31.95,,36.12,percent of total billed charges,31.95% of total billed charges,4452.94,6104,
SURGIPR0 MESH 6X6,4202366,CDM,278,RC,C1781,HCPCS,OUTPATIENT,,,77.92,46.752,,81.82,105,,,case rate,pays based on 105% of threshold rate,38.96,50,,31.168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38.96,50,,31.168,percent of total billed charges,50% of total billed charges,27.39,35.15,,21.912,percent of total billed charges,35.15% of total billed charges,145.05,31.95,,116.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.61,38,,88.768,percent of total billed charges,38% of total billed charges,24.9,31.95,,19.92,percent of total billed charges,31.95% of total billed charges,4453.94,6105,
REFLUX MANAGEMENT SYSTEM LXMC13,4202367,CDM,278,RC,L8699,HCPCS,OUTPATIENT,,,16500,9900,,17325,105,,,case rate,pays based on 105% of threshold rate,8250,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8250,50,,6600,percent of total billed charges,50% of total billed charges,5799.75,35.15,,4639.8,percent of total billed charges,35.15% of total billed charges,145.37,31.95,,116.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6270,38,,88.768,percent of total billed charges,38% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,4454.94,6106,
REFLUX MANAGEMENT SYSTEM LXMC14,4202368,CDM,278,RC,L8699,HCPCS,OUTPATIENT,,,16500,9900,,17325,105,,,case rate,pays based on 105% of threshold rate,8250,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8250,50,,6600,percent of total billed charges,50% of total billed charges,5799.75,35.15,,4639.8,percent of total billed charges,35.15% of total billed charges,145.37,31.95,,116.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6270,38,,919.296,percent of total billed charges,38% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,4455.94,6107,
REFLUX MANAGEMENT SYSTEM LXMC15,4202369,CDM,278,RC,L8699,HCPCS,OUTPATIENT,,,16500,9900,,17325,105,,,case rate,pays based on 105% of threshold rate,8250,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8250,50,,6600,percent of total billed charges,50% of total billed charges,5799.75,35.15,,4639.8,percent of total billed charges,35.15% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6270,38,,18.24,percent of total billed charges,38% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,4456.94,6108,
REFLUX MANAGEMENT SYSTEM LXMC16,4202370,CDM,278,RC,L8699,HCPCS,OUTPATIENT,,,16500,9900,,17325,105,,,case rate,pays based on 105% of threshold rate,8250,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8250,50,,6600,percent of total billed charges,50% of total billed charges,5799.75,35.15,,4639.8,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6270,38,,20.064,percent of total billed charges,38% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,4457.94,6109,
REFLUX MANAGEMENT SYSTEM LXMC17,4202371,CDM,278,RC,L8699,HCPCS,OUTPATIENT,,,16500,9900,,17325,105,,,case rate,pays based on 105% of threshold rate,8250,50,,6600,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8250,50,,6600,percent of total billed charges,50% of total billed charges,5799.75,35.15,,4639.8,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6270,38,,1200.8,percent of total billed charges,38% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,4458.94,6110,
MESH SMALL CIRCLE VENTRAL PROCEED,4202373,CDM,278,RC,C1781,HCPCS,OUTPATIENT,,,2340,1404,,2457,105,,,case rate,pays based on 105% of threshold rate,1170,50,,936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1170,50,,936,percent of total billed charges,50% of total billed charges,822.51,35.15,,658.008,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,889.2,38,,61.408,percent of total billed charges,38% of total billed charges,747.63,31.95,,598.104,percent of total billed charges,31.95% of total billed charges,4459.94,6111,
MESH MEDIUM CIRCLE VENTRAL PROCEED,4202374,CDM,278,RC,C1781,HCPCS,OUTPATIENT,,,2800,1680,,2940,105,,,case rate,pays based on 105% of threshold rate,1400,50,,1120,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1400,50,,1120,percent of total billed charges,50% of total billed charges,984.2,35.15,,787.36,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1064,38,,523.488,percent of total billed charges,38% of total billed charges,894.6,31.95,,715.68,percent of total billed charges,31.95% of total billed charges,4460.94,6112,
MESH 10X14'''' RECTANGLE PROCEED,4202375,CDM,278,RC,C1781,HCPCS,OUTPATIENT,,,2134.3,1280.58,,2241.02,105,,,case rate,pays based on 105% of threshold rate,1067.15,50,,853.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1067.15,50,,853.72,percent of total billed charges,50% of total billed charges,750.21,35.15,,600.168,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,811.03,38,,592.8,percent of total billed charges,38% of total billed charges,681.91,31.95,,545.528,percent of total billed charges,31.95% of total billed charges,4461.94,6113,
MESH 4X8'''' RECTANGLE PROCEED,4202376,CDM,278,RC,C1781,HCPCS,OUTPATIENT,,,2103,1261.8,,2208.15,105,,,case rate,pays based on 105% of threshold rate,1051.5,50,,841.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1051.5,50,,841.2,percent of total billed charges,50% of total billed charges,739.2,35.15,,591.36,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,799.14,38,,919.296,percent of total billed charges,38% of total billed charges,671.91,31.95,,537.528,percent of total billed charges,31.95% of total billed charges,4462.94,6114,
MESH 2X4'''' RECTANGLE PROCEED,4202378,CDM,278,RC,C1781,HCPCS,OUTPATIENT,,,241.94,145.164,,254.04,105,,,case rate,pays based on 105% of threshold rate,120.97,50,,96.776,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,120.97,50,,96.776,percent of total billed charges,50% of total billed charges,85.04,35.15,,68.032,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,91.94,38,,18.24,percent of total billed charges,38% of total billed charges,77.3,31.95,,61.84,percent of total billed charges,31.95% of total billed charges,4463.94,6115,
HUMIDIFIER ELECTRIC COOL MIST,4202384,CDM,270,RC,,,OUTPATIENT,,,180,108,,153,85,,122.4,Percent of total billed charges,85% of total billed charges,90,50,,72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90,50,,72,percent of total billed charges,50% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.4,38,,592.8,percent of total billed charges,38% of total billed charges,72,40,,57.6,percent of total billed charges,40% of total billed charges,4464.94,6116,
"VENTILATOR CIRCUIT, 3 FT",4202386,CDM,270,RC,,,OUTPATIENT,,,840,504,,714,85,,571.2,Percent of total billed charges,85% of total billed charges,420,50,,336,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,420,50,,336,percent of total billed charges,50% of total billed charges,268.38,31.95,,214.704,percent of total billed charges,31.95% of total billed charges,268.38,31.95,,214.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,319.2,38,,96.368,percent of total billed charges,38% of total billed charges,336,40,,268.8,percent of total billed charges,40% of total billed charges,4465.94,6117,
MULTI ADAPTER 22MM,4202387,CDM,270,RC,,,OUTPATIENT,,,32.72,19.632,,27.81,85,,22.248,Percent of total billed charges,85% of total billed charges,16.36,50,,13.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.36,50,,13.088,percent of total billed charges,50% of total billed charges,10.45,31.95,,8.36,percent of total billed charges,31.95% of total billed charges,10.45,31.95,,8.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.43,38,,854.848,percent of total billed charges,38% of total billed charges,13.09,40,,10.472,percent of total billed charges,40% of total billed charges,4466.94,6118,
BUTTERFLY 23G WITH TUBE HOLDER,4202388,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,125.248,percent of total billed charges,38% of total billed charges,0.8,40,,0.64,percent of total billed charges,40% of total billed charges,4467.94,6119,
OPTIRAY 320 PREFILL SYRINGE 125ML,4202389,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,1137.34,682.404,,1194.21,105,,,case rate,pays based on 105% of threshold rate,568.67,50,,454.936,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,568.67,50,,454.936,percent of total billed charges,50% of total billed charges,399.78,35.15,,319.824,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,432.19,38,,501.6,percent of total billed charges,38% of total billed charges,363.38,31.95,,290.704,percent of total billed charges,31.95% of total billed charges,4468.94,6120,
4FR OPEN END URETERAL CATHETER,4202391,CDM,270,RC,,,OUTPATIENT,,,34.8,20.88,,29.58,85,,23.664,Percent of total billed charges,85% of total billed charges,17.4,50,,13.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.4,50,,13.92,percent of total billed charges,50% of total billed charges,11.12,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,11.12,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.22,38,,530.48,percent of total billed charges,38% of total billed charges,13.92,40,,11.136,percent of total billed charges,40% of total billed charges,4469.94,6121,
6FR OPEN END URETERAL CATHETER,4202392,CDM,270,RC,,,OUTPATIENT,,,34.8,20.88,,29.58,85,,23.664,Percent of total billed charges,85% of total billed charges,17.4,50,,13.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.4,50,,13.92,percent of total billed charges,50% of total billed charges,11.12,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,11.12,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.22,38,,592.8,percent of total billed charges,38% of total billed charges,13.92,40,,11.136,percent of total billed charges,40% of total billed charges,4470.94,6122,
ET TUBE   5.0 CUFFED,4202394,CDM,270,RC,,,OUTPATIENT,,,4.6,2.76,,3.91,85,,3.128,Percent of total billed charges,85% of total billed charges,2.3,50,,1.84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.3,50,,1.84,percent of total billed charges,50% of total billed charges,1.47,31.95,,1.176,percent of total billed charges,31.95% of total billed charges,1.47,31.95,,1.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.75,38,,1886.32,percent of total billed charges,38% of total billed charges,1.84,40,,1.472,percent of total billed charges,40% of total billed charges,4471.94,6123,
SCRUB BRUSH W/EXIDINE (PCMX),4202396,CDM,270,RC,,,OUTPATIENT,,,33.1,19.86,,28.14,85,,22.512,Percent of total billed charges,85% of total billed charges,16.55,50,,13.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.55,50,,13.24,percent of total billed charges,50% of total billed charges,10.58,31.95,,8.464,percent of total billed charges,31.95% of total billed charges,10.58,31.95,,8.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.58,38,,1094.4,percent of total billed charges,38% of total billed charges,13.24,40,,10.592,percent of total billed charges,40% of total billed charges,4472.94,6124,
DRESSING ALISITE M 59480200,4202397,CDM,270,RC,,,OUTPATIENT,,,7.2,4.32,,6.12,85,,4.896,Percent of total billed charges,85% of total billed charges,3.6,50,,2.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.6,50,,2.88,percent of total billed charges,50% of total billed charges,2.3,31.95,,1.84,percent of total billed charges,31.95% of total billed charges,2.3,31.95,,1.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.74,38,,592.8,percent of total billed charges,38% of total billed charges,2.88,40,,2.304,percent of total billed charges,40% of total billed charges,4473.94,6125,
TONER HP 39A,4202398,CDM,270,RC,,,OUTPATIENT,,,245.4,147.24,,208.59,85,,166.872,Percent of total billed charges,85% of total billed charges,122.7,50,,98.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,122.7,50,,98.16,percent of total billed charges,50% of total billed charges,78.41,31.95,,62.728,percent of total billed charges,31.95% of total billed charges,78.41,31.95,,62.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,93.25,38,,881.6,percent of total billed charges,38% of total billed charges,98.16,40,,78.528,percent of total billed charges,40% of total billed charges,4474.94,6126,
COVER MAINT STERILITY 16''''X30'''',4202399,CDM,270,RC,,,OUTPATIENT,,,1.8,1.08,,1.53,85,,1.224,Percent of total billed charges,85% of total billed charges,0.9,50,,0.72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.9,50,,0.72,percent of total billed charges,50% of total billed charges,0.58,31.95,,0.464,percent of total billed charges,31.95% of total billed charges,0.58,31.95,,0.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.68,38,,592.8,percent of total billed charges,38% of total billed charges,0.72,40,,0.576,percent of total billed charges,40% of total billed charges,4475.94,6127,
SMART PACK (STERILIZATION),4202400,CDM,270,RC,,,OUTPATIENT,,,9.4,5.64,,7.99,85,,6.392,Percent of total billed charges,85% of total billed charges,4.7,50,,3.76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.7,50,,3.76,percent of total billed charges,50% of total billed charges,3,31.95,,2.4,percent of total billed charges,31.95% of total billed charges,3,31.95,,2.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.57,38,,82.08,percent of total billed charges,38% of total billed charges,3.76,40,,3.008,percent of total billed charges,40% of total billed charges,4476.94,6128,
BALLOON HELIUM KID,4202401,CDM,270,RC,,,OUTPATIENT,,,46.3,27.78,,39.36,85,,31.488,Percent of total billed charges,85% of total billed charges,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.15,50,,18.52,percent of total billed charges,50% of total billed charges,14.79,31.95,,11.832,percent of total billed charges,31.95% of total billed charges,14.79,31.95,,11.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.59,38,,185.44,percent of total billed charges,38% of total billed charges,18.52,40,,14.816,percent of total billed charges,40% of total billed charges,4477.94,6129,
FLEXOR URETERAL ACCESS SHEATH,4202402,CDM,270,RC,,,OUTPATIENT,,,340,204,,289,85,,231.2,Percent of total billed charges,85% of total billed charges,170,50,,136,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,170,50,,136,percent of total billed charges,50% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.2,38,,1635.52,percent of total billed charges,38% of total billed charges,136,40,,108.8,percent of total billed charges,40% of total billed charges,4478.94,6130,
URETERAL SHEATH ACCESS 12FR 55CM,4202403,CDM,270,RC,,,OUTPATIENT,,,424.9,254.94,,361.17,85,,288.936,Percent of total billed charges,85% of total billed charges,212.45,50,,169.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,212.45,50,,169.96,percent of total billed charges,50% of total billed charges,135.76,31.95,,108.608,percent of total billed charges,31.95% of total billed charges,135.76,31.95,,108.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,161.46,38,,55.328,percent of total billed charges,38% of total billed charges,169.96,40,,135.968,percent of total billed charges,40% of total billed charges,4479.94,6131,
PAD STAMP RED,4202404,CDM,270,RC,,,OUTPATIENT,,,7.7,4.62,,6.55,85,,5.24,Percent of total billed charges,85% of total billed charges,3.85,50,,3.08,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.85,50,,3.08,percent of total billed charges,50% of total billed charges,2.46,31.95,,1.968,percent of total billed charges,31.95% of total billed charges,2.46,31.95,,1.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.93,38,,55.328,percent of total billed charges,38% of total billed charges,3.08,40,,2.464,percent of total billed charges,40% of total billed charges,4480.94,6132,
EYE PAD,4202405,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,55.328,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4481.94,6133,
ISOLATION MASK,4202407,CDM,270,RC,,,OUTPATIENT,,,8.7,5.22,,7.4,85,,5.92,Percent of total billed charges,85% of total billed charges,4.35,50,,3.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.35,50,,3.48,percent of total billed charges,50% of total billed charges,2.78,31.95,,2.224,percent of total billed charges,31.95% of total billed charges,2.78,31.95,,2.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.31,38,,55.328,percent of total billed charges,38% of total billed charges,3.48,40,,2.784,percent of total billed charges,40% of total billed charges,4482.94,6134,
TUBEGAUZE 2 5/8''''X50YDS,4202409,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,34.656,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4483.94,6135,
STENT MARDIS URETERAL 6X22,4202411,CDM,270,RC,,,OUTPATIENT,,,479.8,287.88,,407.83,85,,326.264,Percent of total billed charges,85% of total billed charges,239.9,50,,191.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,239.9,50,,191.92,percent of total billed charges,50% of total billed charges,153.3,31.95,,122.64,percent of total billed charges,31.95% of total billed charges,153.3,31.95,,122.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,182.32,38,,123.12,percent of total billed charges,38% of total billed charges,191.92,40,,153.536,percent of total billed charges,40% of total billed charges,4484.94,6136,
STENT MARDIS URETERAL 7X22,4202412,CDM,270,RC,,,OUTPATIENT,,,479.8,287.88,,407.83,85,,326.264,Percent of total billed charges,85% of total billed charges,239.9,50,,191.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,239.9,50,,191.92,percent of total billed charges,50% of total billed charges,153.3,31.95,,122.64,percent of total billed charges,31.95% of total billed charges,153.3,31.95,,122.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,182.32,38,,592.8,percent of total billed charges,38% of total billed charges,191.92,40,,153.536,percent of total billed charges,40% of total billed charges,4485.94,6137,
STENT MARDIS URETERAL 7X24,4202413,CDM,270,RC,,,OUTPATIENT,,,536.4,321.84,,455.94,85,,364.752,Percent of total billed charges,85% of total billed charges,268.2,50,,214.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,268.2,50,,214.56,percent of total billed charges,50% of total billed charges,171.38,31.95,,137.104,percent of total billed charges,31.95% of total billed charges,171.38,31.95,,137.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,203.83,38,,162.336,percent of total billed charges,38% of total billed charges,214.56,40,,171.648,percent of total billed charges,40% of total billed charges,4486.94,6138,
WOUND RETRACTOR SMALL 2.5-6CM,4202414,CDM,270,RC,,,OUTPATIENT,,,123.1,73.86,,104.64,85,,83.712,Percent of total billed charges,85% of total billed charges,61.55,50,,49.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,61.55,50,,49.24,percent of total billed charges,50% of total billed charges,39.33,31.95,,31.464,percent of total billed charges,31.95% of total billed charges,39.33,31.95,,31.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,46.78,38,,120.992,percent of total billed charges,38% of total billed charges,49.24,40,,39.392,percent of total billed charges,40% of total billed charges,4487.94,6139,
DRESSING GEL (SAF-GEL),4202415,CDM,270,RC,,,OUTPATIENT,,,14.2,8.52,,12.07,85,,9.656,Percent of total billed charges,85% of total billed charges,7.1,50,,5.68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.1,50,,5.68,percent of total billed charges,50% of total billed charges,4.54,31.95,,3.632,percent of total billed charges,31.95% of total billed charges,4.54,31.95,,3.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.4,38,,177.536,percent of total billed charges,38% of total billed charges,5.68,40,,4.544,percent of total billed charges,40% of total billed charges,4488.94,6140,
ARM SLING 2XSM,4202416,CDM,270,RC,,,OUTPATIENT,,,3.1,1.86,,2.64,85,,2.112,Percent of total billed charges,85% of total billed charges,1.55,50,,1.24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.55,50,,1.24,percent of total billed charges,50% of total billed charges,0.99,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,0.99,31.95,,0.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.18,38,,145.616,percent of total billed charges,38% of total billed charges,1.24,40,,0.992,percent of total billed charges,40% of total billed charges,4489.94,6141,
RESERVIOR JACKSON PRATT 100ML,4202417,CDM,270,RC,,,OUTPATIENT,,,10.4,6.24,,8.84,85,,7.072,Percent of total billed charges,85% of total billed charges,5.2,50,,4.16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.2,50,,4.16,percent of total billed charges,50% of total billed charges,3.32,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,3.32,31.95,,2.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.95,38,,108.528,percent of total billed charges,38% of total billed charges,4.16,40,,3.328,percent of total billed charges,40% of total billed charges,4490.94,6142,
THORACENTESIS/PARACENTESIS TRAY,4202418,CDM,270,RC,,,OUTPATIENT,,,71.3,42.78,,60.61,85,,48.488,Percent of total billed charges,85% of total billed charges,35.65,50,,28.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.65,50,,28.52,percent of total billed charges,50% of total billed charges,22.78,31.95,,18.224,percent of total billed charges,31.95% of total billed charges,22.78,31.95,,18.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.09,38,,108.528,percent of total billed charges,38% of total billed charges,28.52,40,,22.816,percent of total billed charges,40% of total billed charges,4491.94,6143,
FMC THORACENTESIS/PARACENTESIS TRAY,4202418,CDM,270,RC,,,OUTPATIENT,,,71.3,42.78,,60.61,85,,48.488,Percent of total billed charges,85% of total billed charges,35.65,50,,28.52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.65,50,,28.52,percent of total billed charges,50% of total billed charges,22.78,31.95,,18.224,percent of total billed charges,31.95% of total billed charges,22.78,31.95,,18.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.09,38,,592.8,percent of total billed charges,38% of total billed charges,28.52,40,,22.816,percent of total billed charges,40% of total billed charges,4492.94,6144,
LARYNGEAL MASK AIRWAY SIZE #4,4202420,CDM,270,RC,,,OUTPATIENT,,,21.4,12.84,,18.19,85,,14.552,Percent of total billed charges,85% of total billed charges,10.7,50,,8.56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.7,50,,8.56,percent of total billed charges,50% of total billed charges,6.84,31.95,,5.472,percent of total billed charges,31.95% of total billed charges,6.84,31.95,,5.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.13,38,,133.152,percent of total billed charges,38% of total billed charges,8.56,40,,6.848,percent of total billed charges,40% of total billed charges,4493.94,6145,
PULSE A VAC,4202421,CDM,270,RC,,,OUTPATIENT,,,158,94.8,,134.3,85,,107.44,Percent of total billed charges,85% of total billed charges,79,50,,63.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,79,50,,63.2,percent of total billed charges,50% of total billed charges,50.48,31.95,,40.384,percent of total billed charges,31.95% of total billed charges,50.48,31.95,,40.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.04,38,,40.128,percent of total billed charges,38% of total billed charges,63.2,40,,50.56,percent of total billed charges,40% of total billed charges,4494.94,6146,
DISPOSABLE INJECTOR NM,4202422,CDM,272,RC,,,OUTPATIENT,,,74.6,44.76,,63.41,85,,50.728,Percent of total billed charges,85% of total billed charges,37.3,50,,29.84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.3,50,,29.84,percent of total billed charges,50% of total billed charges,23.83,31.95,,19.064,percent of total billed charges,31.95% of total billed charges,23.83,31.95,,19.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.35,38,,89.376,percent of total billed charges,38% of total billed charges,29.84,40,,23.872,percent of total billed charges,40% of total billed charges,4495.94,6147,
STONE EXTRACTOR 4 WIRE 3.2,4202423,CDM,272,RC,,,OUTPATIENT,,,584.7,350.82,,497,85,,397.6,Percent of total billed charges,85% of total billed charges,292.35,50,,233.88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,292.35,50,,233.88,percent of total billed charges,50% of total billed charges,186.81,31.95,,149.448,percent of total billed charges,31.95% of total billed charges,186.81,31.95,,149.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,222.19,38,,89.376,percent of total billed charges,38% of total billed charges,233.88,40,,187.104,percent of total billed charges,40% of total billed charges,4496.94,6148,
ZIPWIRE GLIDEWIRE .038/150 STD STRAIGHT,4202425,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,113.2,67.92,,118.86,105,,,case rate,pays based on 105% of threshold rate,56.6,50,,45.28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.6,50,,45.28,percent of total billed charges,50% of total billed charges,39.79,35.15,,31.832,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.02,38,,89.376,percent of total billed charges,38% of total billed charges,36.17,31.95,,28.936,percent of total billed charges,31.95% of total billed charges,4497.94,6149,
5FR OPEN-END URETERAL CATHETER,4202426,CDM,270,RC,,,OUTPATIENT,,,34.8,20.88,,29.58,85,,23.664,Percent of total billed charges,85% of total billed charges,17.4,50,,13.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.4,50,,13.92,percent of total billed charges,50% of total billed charges,11.12,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,11.12,31.95,,8.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.22,38,,103.664,percent of total billed charges,38% of total billed charges,13.92,40,,11.136,percent of total billed charges,40% of total billed charges,4498.94,6150,
7FR OPEN END URETERAL CATHETER,4202427,CDM,270,RC,,,OUTPATIENT,,,35.9,21.54,,30.52,85,,24.416,Percent of total billed charges,85% of total billed charges,17.95,50,,14.36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.95,50,,14.36,percent of total billed charges,50% of total billed charges,11.47,31.95,,9.176,percent of total billed charges,31.95% of total billed charges,11.47,31.95,,9.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.64,38,,366.32,percent of total billed charges,38% of total billed charges,14.36,40,,11.488,percent of total billed charges,40% of total billed charges,4499.94,6151,
STENT MARDIS URETERAL 7X28,4202428,CDM,270,RC,,,OUTPATIENT,,,479.8,287.88,,407.83,85,,326.264,Percent of total billed charges,85% of total billed charges,239.9,50,,191.92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,239.9,50,,191.92,percent of total billed charges,50% of total billed charges,153.3,31.95,,122.64,percent of total billed charges,31.95% of total billed charges,153.3,31.95,,122.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,182.32,38,,501.6,percent of total billed charges,38% of total billed charges,191.92,40,,153.536,percent of total billed charges,40% of total billed charges,4500.94,6152,
URETERAL SHEATH ACCESS 14FR 55CM,4202429,CDM,270,RC,,,OUTPATIENT,,,424.9,254.94,,361.17,85,,288.936,Percent of total billed charges,85% of total billed charges,212.45,50,,169.96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,212.45,50,,169.96,percent of total billed charges,50% of total billed charges,135.76,31.95,,108.608,percent of total billed charges,31.95% of total billed charges,135.76,31.95,,108.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,161.46,38,,775.2,percent of total billed charges,38% of total billed charges,169.96,40,,135.968,percent of total billed charges,40% of total billed charges,4501.94,6153,
STENT MARDIS URETERAL 6X24,4202430,CDM,270,RC,,,OUTPATIENT,,,673.6,404.16,,572.56,85,,458.048,Percent of total billed charges,85% of total billed charges,336.8,50,,269.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,336.8,50,,269.44,percent of total billed charges,50% of total billed charges,215.22,31.95,,172.176,percent of total billed charges,31.95% of total billed charges,215.22,31.95,,172.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,255.97,38,,592.8,percent of total billed charges,38% of total billed charges,269.44,40,,215.552,percent of total billed charges,40% of total billed charges,4502.94,6154,
OXYGEN/HR ANES,4202432,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,289.104,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4503.94,6155,
CATHETER 8FR RED RUBBER (STERILE BULK),4202436,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,120.08,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4504.94,6156,
CUTTER 45MM ARTICULATING,4202439,CDM,270,RC,,,OUTPATIENT,,,315.24,189.144,,267.95,85,,214.36,Percent of total billed charges,85% of total billed charges,157.62,50,,126.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,157.62,50,,126.096,percent of total billed charges,50% of total billed charges,100.72,31.95,,80.576,percent of total billed charges,31.95% of total billed charges,100.72,31.95,,80.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,119.79,38,,1392.32,percent of total billed charges,38% of total billed charges,126.1,40,,100.88,percent of total billed charges,40% of total billed charges,4505.94,6157,
SCD KNEE LARGE,4202444,CDM,270,RC,,,OUTPATIENT,,,103,61.8,,87.55,85,,70.04,Percent of total billed charges,85% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,32.91,31.95,,26.328,percent of total billed charges,31.95% of total billed charges,32.91,31.95,,26.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.14,38,,116.736,percent of total billed charges,38% of total billed charges,41.2,40,,32.96,percent of total billed charges,40% of total billed charges,4506.94,6158,
SUTURE 2.0 VICRYL SH SH/SV-20,4202446,CDM,270,RC,,,OUTPATIENT,,,15.5,9.3,,13.18,85,,10.544,Percent of total billed charges,85% of total billed charges,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,4.95,31.95,,3.96,percent of total billed charges,31.95% of total billed charges,4.95,31.95,,3.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.89,38,,116.736,percent of total billed charges,38% of total billed charges,6.2,40,,4.96,percent of total billed charges,40% of total billed charges,4507.94,6159,
SUTURE 4.0 ETHILON FS-2,4202447,CDM,270,RC,,,OUTPATIENT,,,16.18,9.708,,13.75,85,,11,Percent of total billed charges,85% of total billed charges,8.09,50,,6.472,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.09,50,,6.472,percent of total billed charges,50% of total billed charges,5.17,31.95,,4.136,percent of total billed charges,31.95% of total billed charges,5.17,31.95,,4.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.15,38,,116.736,percent of total billed charges,38% of total billed charges,6.47,40,,5.176,percent of total billed charges,40% of total billed charges,4508.94,6160,
STAPLER RELOAD THICK TISSUE,4202448,CDM,270,RC,,,OUTPATIENT,,,317.35,190.41,,269.75,85,,215.8,Percent of total billed charges,85% of total billed charges,158.68,50,,126.944,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,158.68,50,,126.944,percent of total billed charges,50% of total billed charges,101.39,31.95,,81.112,percent of total billed charges,31.95% of total billed charges,101.39,31.95,,81.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,120.59,38,,116.736,percent of total billed charges,38% of total billed charges,126.94,40,,101.552,percent of total billed charges,40% of total billed charges,4509.94,6161,
SLEEVE STABILITY 11MM DIA 100MM,4202449,CDM,270,RC,,,OUTPATIENT,,,103,61.8,,87.55,85,,70.04,Percent of total billed charges,85% of total billed charges,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,51.5,50,,41.2,percent of total billed charges,50% of total billed charges,32.91,31.95,,26.328,percent of total billed charges,31.95% of total billed charges,32.91,31.95,,26.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.14,38,,116.736,percent of total billed charges,38% of total billed charges,41.2,40,,32.96,percent of total billed charges,40% of total billed charges,4510.94,6162,
MESH LARGE PLUG AND PATCH,4202450,CDM,270,RC,,,OUTPATIENT,,,1050,630,,892.5,85,,714,Percent of total billed charges,85% of total billed charges,525,50,,420,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,525,50,,420,percent of total billed charges,50% of total billed charges,335.48,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,335.48,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,399,38,,116.736,percent of total billed charges,38% of total billed charges,420,40,,336,percent of total billed charges,40% of total billed charges,4511.94,6163,
Mesh Plug and Patch,4202451,CDM,270,RC,,,OUTPATIENT,,,1050,630,,892.5,85,,714,Percent of total billed charges,85% of total billed charges,525,50,,420,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,525,50,,420,percent of total billed charges,50% of total billed charges,335.48,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,335.48,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,399,38,,116.736,percent of total billed charges,38% of total billed charges,420,40,,336,percent of total billed charges,40% of total billed charges,4512.94,6164,
NEEDLE COLD KNIFE HF 45 DEGREE 12/30 DEGREE,4202452,CDM,270,RC,,,OUTPATIENT,,,1460,876,,1241,85,,992.8,Percent of total billed charges,85% of total billed charges,730,50,,584,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,730,50,,584,percent of total billed charges,50% of total billed charges,466.47,31.95,,373.176,percent of total billed charges,31.95% of total billed charges,466.47,31.95,,373.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,554.8,38,,1816.096,percent of total billed charges,38% of total billed charges,584,40,,467.2,percent of total billed charges,40% of total billed charges,4513.94,6165,
SHILEY TRACH UNCUFFED 4CFS,4202453,CDM,270,RC,,,OUTPATIENT,,,130,78,,110.5,85,,88.4,Percent of total billed charges,85% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,65,50,,52,percent of total billed charges,50% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.4,38,,377.872,percent of total billed charges,38% of total billed charges,52,40,,41.6,percent of total billed charges,40% of total billed charges,4514.94,6166,
SHILEY TRACH UNCUFFED 10CFS,4202454,CDM,270,RC,,,OUTPATIENT,,,130,78,,110.5,85,,88.4,Percent of total billed charges,85% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,65,50,,52,percent of total billed charges,50% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.4,38,,228,percent of total billed charges,38% of total billed charges,52,40,,41.6,percent of total billed charges,40% of total billed charges,4515.94,6167,
16FR 30CC foley catheter,4202455,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,501.6,percent of total billed charges,38% of total billed charges,11.2,40,,8.96,percent of total billed charges,40% of total billed charges,4516.94,6168,
RHINO ROCKET SLIMELINE LARGE,4202457,CDM,270,RC,,,OUTPATIENT,,,40.78,24.468,,34.66,85,,27.728,Percent of total billed charges,85% of total billed charges,20.39,50,,16.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.39,50,,16.312,percent of total billed charges,50% of total billed charges,13.03,31.95,,10.424,percent of total billed charges,31.95% of total billed charges,13.03,31.95,,10.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.5,38,,431.68,percent of total billed charges,38% of total billed charges,16.31,40,,13.048,percent of total billed charges,40% of total billed charges,4517.94,6169,
CATHETER FOLEY 20FR 30CC,4202458,CDM,270,RC,,,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,186.048,percent of total billed charges,38% of total billed charges,9.6,40,,7.68,percent of total billed charges,40% of total billed charges,4518.94,6170,
MESH TINTRA SKIRTED CK-7,4202459,CDM,270,RC,,,OUTPATIENT,,,1000,600,,850,85,,680,Percent of total billed charges,85% of total billed charges,500,50,,400,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,500,50,,400,percent of total billed charges,50% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,504.032,percent of total billed charges,38% of total billed charges,400,40,,320,percent of total billed charges,40% of total billed charges,4519.94,6171,
ANESTHESIA BREATHING CIRCUIT PEDIATRIC,4202462,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,16.72,percent of total billed charges,38% of total billed charges,18.4,40,,14.72,percent of total billed charges,40% of total billed charges,4520.94,6172,
SUTURE 3.0 SURGIPRO CV-23,4202463,CDM,270,RC,,,OUTPATIENT,,,13.04,7.824,,11.08,85,,8.864,Percent of total billed charges,85% of total billed charges,6.52,50,,5.216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.52,50,,5.216,percent of total billed charges,50% of total billed charges,4.17,31.95,,3.336,percent of total billed charges,31.95% of total billed charges,4.17,31.95,,3.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.96,38,,10.64,percent of total billed charges,38% of total billed charges,5.22,40,,4.176,percent of total billed charges,40% of total billed charges,4521.94,6173,
FOLEY CATH 22FR 30CC Charge,4202464,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,33.44,percent of total billed charges,38% of total billed charges,10.8,40,,8.64,percent of total billed charges,40% of total billed charges,4522.94,6174,
EXPRESS BALLOON CATHETER BARRX360,4202465,CDM,270,RC,,,OUTPATIENT,,,3565,2139,,3030.25,85,,2424.2,Percent of total billed charges,85% of total billed charges,1782.5,50,,1426,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1782.5,50,,1426,percent of total billed charges,50% of total billed charges,1139.02,31.95,,911.216,percent of total billed charges,31.95% of total billed charges,1139.02,31.95,,911.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1354.7,38,,28.88,percent of total billed charges,38% of total billed charges,1426,40,,1140.8,percent of total billed charges,40% of total billed charges,4523.94,6175,
FOCAL CATHETER BARRX90,4202466,CDM,270,RC,,,OUTPATIENT,,,2325,1395,,1976.25,85,,1581,Percent of total billed charges,85% of total billed charges,1162.5,50,,930,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1162.5,50,,930,percent of total billed charges,50% of total billed charges,742.84,31.95,,594.272,percent of total billed charges,31.95% of total billed charges,742.84,31.95,,594.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,883.5,38,,23.712,percent of total billed charges,38% of total billed charges,930,40,,744,percent of total billed charges,40% of total billed charges,4524.94,6176,
TROCAR 5X75 APPLIED BALLOON,4202467,CDM,270,RC,,,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.28,38,,91.2,percent of total billed charges,38% of total billed charges,22.4,40,,17.92,percent of total billed charges,40% of total billed charges,4525.94,6177,
RHINO ROCKET LG,4202468,CDM,270,RC,,,OUTPATIENT,,,40.78,24.468,,34.66,85,,27.728,Percent of total billed charges,85% of total billed charges,20.39,50,,16.312,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20.39,50,,16.312,percent of total billed charges,50% of total billed charges,13.03,31.95,,10.424,percent of total billed charges,31.95% of total billed charges,13.03,31.95,,10.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.5,38,,7.6,percent of total billed charges,38% of total billed charges,16.31,40,,13.048,percent of total billed charges,40% of total billed charges,4526.94,6178,
Supplies,4202469,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,120,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4527.94,6179,
SUTURE 3.0 PDS II SH-1 CV-25,4202470,CDM,270,RC,,,OUTPATIENT,,,12.74,7.644,,10.83,85,,8.664,Percent of total billed charges,85% of total billed charges,6.37,50,,5.096,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.37,50,,5.096,percent of total billed charges,50% of total billed charges,4.07,31.95,,3.256,percent of total billed charges,31.95% of total billed charges,4.07,31.95,,3.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.84,38,,51.984,percent of total billed charges,38% of total billed charges,5.1,40,,4.08,percent of total billed charges,40% of total billed charges,4528.94,6180,
COLOSTOMY DRAIN BAG 2.25'',4202471,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,40.736,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4529.94,6181,
ESMARK BANDAGE 4''X3YDS,4202472,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,40.736,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,4530.94,6182,
RESOLUTION 360 CLIP HEMOCLIP,4202477,CDM,270,RC,,,OUTPATIENT,,,842,505.2,,715.7,85,,572.56,Percent of total billed charges,85% of total billed charges,421,50,,336.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,421,50,,336.8,percent of total billed charges,50% of total billed charges,269.02,31.95,,215.216,percent of total billed charges,31.95% of total billed charges,269.02,31.95,,215.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,319.96,38,,47.728,percent of total billed charges,38% of total billed charges,336.8,40,,269.44,percent of total billed charges,40% of total billed charges,4531.94,6183,
"ESOPHAGEAL BALLOON DILATATION CATHETER 18MM, 19MM, 20MM",4202478,CDM,270,RC,,,OUTPATIENT,,,740,444,,629,85,,503.2,Percent of total billed charges,85% of total billed charges,370,50,,296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,370,50,,296,percent of total billed charges,50% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,281.2,38,,47.728,percent of total billed charges,38% of total billed charges,296,40,,236.8,percent of total billed charges,40% of total billed charges,4532.94,6184,
"ESOPHAGEAL BALLOON DILATATION CATHETER 15MM, 16.5MM, 18MM",4202479,CDM,270,RC,,,OUTPATIENT,,,740,444,,629,85,,503.2,Percent of total billed charges,85% of total billed charges,370,50,,296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,370,50,,296,percent of total billed charges,50% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,281.2,38,,32.528,percent of total billed charges,38% of total billed charges,296,40,,236.8,percent of total billed charges,40% of total billed charges,4533.94,6185,
"ESOPHAGEAL BALLOON DILATATION CATHETER 10MM, 11MM, 12MM",4202481,CDM,270,RC,,,OUTPATIENT,,,720,432,,612,85,,489.6,Percent of total billed charges,85% of total billed charges,360,50,,288,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,360,50,,288,percent of total billed charges,50% of total billed charges,230.04,31.95,,184.032,percent of total billed charges,31.95% of total billed charges,230.04,31.95,,184.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,273.6,38,,51.072,percent of total billed charges,38% of total billed charges,288,40,,230.4,percent of total billed charges,40% of total billed charges,4534.94,6186,
"BARRX RFS CLEANING CAP, SMALL",4202483,CDM,270,RC,,,OUTPATIENT,,,108,64.8,,91.8,85,,73.44,Percent of total billed charges,85% of total billed charges,54,50,,43.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,54,50,,43.2,percent of total billed charges,50% of total billed charges,34.51,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,34.51,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.04,38,,69.92,percent of total billed charges,38% of total billed charges,43.2,40,,34.56,percent of total billed charges,40% of total billed charges,4535.94,6187,
INJECTOR SYRINGE ASSEMBLY,4202484,CDM,270,RC,,,OUTPATIENT,,,684,410.4,,581.4,85,,465.12,Percent of total billed charges,85% of total billed charges,342,50,,273.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,342,50,,273.6,percent of total billed charges,50% of total billed charges,218.54,31.95,,174.832,percent of total billed charges,31.95% of total billed charges,218.54,31.95,,174.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,259.92,38,,25.84,percent of total billed charges,38% of total billed charges,273.6,40,,218.88,percent of total billed charges,40% of total billed charges,4536.94,6188,
FMC BARD NDLBIOP 14GX10CM MXCR,4202485,CDM,270,RC,,,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,25.84,percent of total billed charges,38% of total billed charges,80,40,,64,percent of total billed charges,40% of total billed charges,4537.94,6189,
BREAST BIOPSY GUN 14GX10CM,4202485,CDM,270,RC,,,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,120,50,,96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,120,50,,96,percent of total billed charges,50% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,91.2,38,,46.208,percent of total billed charges,38% of total billed charges,96,40,,76.8,percent of total billed charges,40% of total billed charges,4538.94,6190,
BREAST BIOPSY GUN 14GX10CM,4202485,CDM,270,RC,,,OUTPATIENT,,,68,40.8,,57.8,85,,46.24,Percent of total billed charges,85% of total billed charges,34,50,,27.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34,50,,27.2,percent of total billed charges,50% of total billed charges,21.73,31.95,,17.384,percent of total billed charges,31.95% of total billed charges,21.73,31.95,,17.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.84,38,,34.96,percent of total billed charges,38% of total billed charges,27.2,40,,21.76,percent of total billed charges,40% of total billed charges,4539.94,6191,
BALEEN POLYP TRAP,4202486,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,45.296,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4540.94,6192,
URINE METER 16FR FOLEY TRAY W/STABILIZATION DEVICE,4202487,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,2.872,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4541.94,6193,
URINE METER 18FR FOLEY TRAY W/STABILIZATION DEVICE,4202488,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,48.64,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4542.94,6194,
OXYGEN DELIVERY MODULE (PINK/RED),4202489,CDM,270,RC,,,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.5,50,,26,percent of total billed charges,50% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,88.16,percent of total billed charges,38% of total billed charges,26,40,,20.8,percent of total billed charges,40% of total billed charges,4543.94,6195,
OXYGEN DELIVERY MODULE (PURPLE),4202490,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,60.8,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,4544.94,6196,
OXYGEN DELIVERY MODULE (YELLOW),4202491,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,2.872,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,4545.94,6197,
OXYGEN DELIVERY MODULE (WHITE),4202492,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,6.08,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,4546.94,6198,
OXYGEN DELIVERY MODULE (BLUE),4202493,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,4.624,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,4547.94,6199,
OXYGEN DELIVERY MODULE (ORANGE),4202494,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,2.872,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,4548.94,6200,
OXYGEN DELIVERY MODULE (GREEN),4202495,CDM,270,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,2.872,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,4549.94,6201,
INTUBATION MODULE  (PINK/RED,4202496,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,19.76,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,4550.94,6202,
INTUBATION MODULE  (PURPLE),4202497,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,49.552,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,4551.94,6203,
INTUBATION MODULE  (YELLOW),4202498,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,97.888,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,4552.94,6204,
INTUBATION MODULE  (WHITE),4202499,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,15.2,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,4553.94,6205,
SUTURE 3.0 VICRYL GS-22,4202500,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,6.08,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4554.94,6206,
SUTURE 0.0 POLYSORB CT-1 GS-21,4202500,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,25.84,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4555.94,6207,
INTUBATION MODULE (BLUE),4202500,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,98.8,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,4556.94,6208,
SUTURE 0.0 POLYSORB CT-2,4202501,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,78.128,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4557.94,6209,
INTUBATION MODULE (ORANGE),4202501,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,97.888,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,4558.94,6210,
SUTURE 0.0 POLYSORB TIES,4202502,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,30.4,percent of total billed charges,38% of total billed charges,10.8,40,,8.64,percent of total billed charges,40% of total billed charges,4559.94,6211,
INTUBATION MODULE (GREEN),4202502,CDM,270,RC,,,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,47,50,,37.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47,50,,37.6,percent of total billed charges,50% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,71.136,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,4560.94,6212,
SUTURE 0.0 SOFSILK BLACK TIES,4202503,CDM,270,RC,,,OUTPATIENT,,,13.5,8.1,,11.48,85,,9.184,Percent of total billed charges,85% of total billed charges,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.75,50,,5.4,percent of total billed charges,50% of total billed charges,4.31,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,4.31,31.95,,3.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.13,38,,30.4,percent of total billed charges,38% of total billed charges,5.4,40,,4.32,percent of total billed charges,40% of total billed charges,4561.94,6213,
I.V. DELIVERY MODULE (PINK/RED),4202503,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,48.944,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4562.94,6214,
SUTURE 0.0 SURGIPRO HGS-22,4202504,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,58.672,percent of total billed charges,38% of total billed charges,8.8,40,,7.04,percent of total billed charges,40% of total billed charges,4563.94,6215,
I.V. DELIVERY MODULE (PURPLE),4202504,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,51.68,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4564.94,6216,
SUTURE 1.0 POLYSORB 36'''' GS-25,4202505,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,46.208,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4565.94,6217,
I.V. DELIVERY MODULE (YELLOW),4202505,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,3.04,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4566.94,6218,
SUTURE 1.0 POLYSORB CT-1 GS-21,4202506,CDM,270,RC,,,OUTPATIENT,,,11.5,6.9,,9.78,85,,7.824,Percent of total billed charges,85% of total billed charges,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.37,38,,13.68,percent of total billed charges,38% of total billed charges,4.6,40,,3.68,percent of total billed charges,40% of total billed charges,4567.94,6219,
I.V. DELIVERY MODULE (WHITE),4202506,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,62.624,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4568.94,6220,
SUTURE 1.0 SURGIPRO CT-1 GS-21,4202507,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,87.552,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,4569.94,6221,
SUTURE 2.0 MONOSOF LS GS-18,4202508,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,172.064,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4570.94,6222,
I.V. DELIVERY MODULE (ORANGE),4202508,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,109.44,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4571.94,6223,
SUTURE 2.0 MONOSRYL SH V-20,4202509,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,77.52,percent of total billed charges,38% of total billed charges,8.8,40,,7.04,percent of total billed charges,40% of total billed charges,4572.94,6224,
I.V. DELIVERY MODULE (GREEN),4202509,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,45.296,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4573.94,6225,
SUTURE 2.0 POLYSORB CT1 GS21,4202510,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,29.792,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4574.94,6226,
INTRAOSSEOUS MODULE (PINK/RED),4202510,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,100.016,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4575.94,6227,
SUTURE 2.0 POLYSORB GU-45,4202511,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,24.32,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4576.94,6228,
INTRAOSSEOUS MODULE (PURPLE),4202511,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,18.24,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4577.94,6229,
SUTURE 2.0 POLYSORB TIES,4202512,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,65.664,percent of total billed charges,38% of total billed charges,10.8,40,,8.64,percent of total billed charges,40% of total billed charges,4578.94,6230,
INTRAOSSEOUS MODULE (YELLOW),4202512,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,46.512,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4579.94,6231,
SUTURE 2.0 SOFSILK TIES,4202513,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,30.4,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4580.94,6232,
INTRAOSSEOUS MODULE (WHITE),4202513,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,30.4,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4581.94,6233,
SUTURE 2.0 SURGIPRO CT1 GS-21,4202514,CDM,270,RC,,,OUTPATIENT,,,11.5,6.9,,9.78,85,,7.824,Percent of total billed charges,85% of total billed charges,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.37,38,,30.4,percent of total billed charges,38% of total billed charges,4.6,40,,3.68,percent of total billed charges,40% of total billed charges,4582.94,6234,
INTRAOSSEOUS MODULE (BLUE),4202514,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,61.104,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4583.94,6235,
SUTURE 2.0 VICRYL CT1,4202515,CDM,270,RC,,,OUTPATIENT,,,9.5,5.7,,8.08,85,,6.464,Percent of total billed charges,85% of total billed charges,4.75,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.75,50,,3.8,percent of total billed charges,50% of total billed charges,3.04,31.95,,2.432,percent of total billed charges,31.95% of total billed charges,3.04,31.95,,2.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.61,38,,51.68,percent of total billed charges,38% of total billed charges,3.8,40,,3.04,percent of total billed charges,40% of total billed charges,4584.94,6236,
INTRAOSSEOUS MODULE (ORANGE),4202515,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,46.208,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4585.94,6237,
SUTURE 3.0 CHROMIC CV-25,4202516,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,53.2,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,4586.94,6238,
INTRAOSSEOUS MODULE (GREEN),4202516,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,57.76,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4587.94,6239,
SUTURE 3.0 MONOSOFT C17,4202518,CDM,270,RC,,,OUTPATIENT,,,9.5,5.7,,8.08,85,,6.464,Percent of total billed charges,85% of total billed charges,4.75,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.75,50,,3.8,percent of total billed charges,50% of total billed charges,3.04,31.95,,2.432,percent of total billed charges,31.95% of total billed charges,3.04,31.95,,2.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.61,38,,46.208,percent of total billed charges,38% of total billed charges,3.8,40,,3.04,percent of total billed charges,40% of total billed charges,4588.94,6240,
SUTURE 3.0 MONOSOFT FS-1 C-14,4202519,CDM,270,RC,,,OUTPATIENT,,,9.5,5.7,,8.08,85,,6.464,Percent of total billed charges,85% of total billed charges,4.75,50,,3.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.75,50,,3.8,percent of total billed charges,50% of total billed charges,3.04,31.95,,2.432,percent of total billed charges,31.95% of total billed charges,3.04,31.95,,2.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.61,38,,41.952,percent of total billed charges,38% of total billed charges,3.8,40,,3.04,percent of total billed charges,40% of total billed charges,4589.94,6241,
SUTURE 3.0 MONOSOFT P-12,4202520,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,34.96,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4590.94,6242,
SUTURE 3.0 POLYSORB CT2 GS22,4202522,CDM,270,RC,,,OUTPATIENT,,,11.5,6.9,,9.78,85,,7.824,Percent of total billed charges,85% of total billed charges,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.37,38,,34.96,percent of total billed charges,38% of total billed charges,4.6,40,,3.68,percent of total billed charges,40% of total billed charges,4591.94,6243,
SUTURE 3.0 POLYSORB GS-22,4202523,CDM,270,RC,,,OUTPATIENT,,,11.5,6.9,,9.78,85,,7.824,Percent of total billed charges,85% of total billed charges,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.37,38,,2.872,percent of total billed charges,38% of total billed charges,4.6,40,,3.68,percent of total billed charges,40% of total billed charges,4592.94,6244,
SUTURE 3.0 POLYSORB P-S-1 P14,4202524,CDM,270,RC,,,OUTPATIENT,,,18.5,11.1,,15.73,85,,12.584,Percent of total billed charges,85% of total billed charges,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,5.91,31.95,,4.728,percent of total billed charges,31.95% of total billed charges,5.91,31.95,,4.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.03,38,,45.6,percent of total billed charges,38% of total billed charges,7.4,40,,5.92,percent of total billed charges,40% of total billed charges,4593.94,6245,
SUTURE 3.0 SOFSILK TIES,4202525,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,20.064,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4594.94,6246,
SUTURE 3.0 SOFTSILK C-23,4202526,CDM,270,RC,,,OUTPATIENT,,,10.5,6.3,,8.93,85,,7.144,Percent of total billed charges,85% of total billed charges,5.25,50,,4.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.25,50,,4.2,percent of total billed charges,50% of total billed charges,3.35,31.95,,2.68,percent of total billed charges,31.95% of total billed charges,3.35,31.95,,2.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.99,38,,51.68,percent of total billed charges,38% of total billed charges,4.2,40,,3.36,percent of total billed charges,40% of total billed charges,4595.94,6247,
SUTURE 3.0 SOFTSILK SH V-20,4202527,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,24.32,percent of total billed charges,38% of total billed charges,7.6,40,,6.08,percent of total billed charges,40% of total billed charges,4596.94,6248,
SUTURE 3.0 SURGIGUT V-20,4202528,CDM,270,RC,,,OUTPATIENT,,,15.5,9.3,,13.18,85,,10.544,Percent of total billed charges,85% of total billed charges,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.75,50,,6.2,percent of total billed charges,50% of total billed charges,4.95,31.95,,3.96,percent of total billed charges,31.95% of total billed charges,4.95,31.95,,3.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.89,38,,1.824,percent of total billed charges,38% of total billed charges,6.2,40,,4.96,percent of total billed charges,40% of total billed charges,4597.94,6249,
SUTURE 3.0 VICRYL PS-4C,4202529,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,6.384,percent of total billed charges,38% of total billed charges,7.6,40,,6.08,percent of total billed charges,40% of total billed charges,4598.94,6250,
SUTURE 4.0 CHROMIC P-12,4202531,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,27.36,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4599.94,6251,
SUTURE 4.0 ETHILON PC-1,4202532,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,24.32,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4600.94,6252,
SUTURE 4.0 MONOSOF C-13,4202533,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,69.008,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4601.94,6253,
SUTURE 4.0 MONOSOF C-16,4202534,CDM,270,RC,,,OUTPATIENT,,,11.5,6.9,,9.78,85,,7.824,Percent of total billed charges,85% of total billed charges,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.37,38,,15.808,percent of total billed charges,38% of total billed charges,4.6,40,,3.68,percent of total billed charges,40% of total billed charges,4602.94,6254,
SUTURE 4.0 MONOSOFT C13,4202535,CDM,270,RC,,,OUTPATIENT,,,11.5,6.9,,9.78,85,,7.824,Percent of total billed charges,85% of total billed charges,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.37,38,,100.928,percent of total billed charges,38% of total billed charges,4.6,40,,3.68,percent of total billed charges,40% of total billed charges,4603.94,6255,
SUTURE 4.0 MONOSOFT C-13,4202536,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,94.848,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4604.94,6256,
SUTURE 4.0 MONOSOFT C14,4202537,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,70.832,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4605.94,6257,
SUTURE 4.0 MONOSOFT P-11,4202538,CDM,270,RC,,,OUTPATIENT,,,18.5,11.1,,15.73,85,,12.584,Percent of total billed charges,85% of total billed charges,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,5.91,31.95,,4.728,percent of total billed charges,31.95% of total billed charges,5.91,31.95,,4.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.03,38,,75.696,percent of total billed charges,38% of total billed charges,7.4,40,,5.92,percent of total billed charges,40% of total billed charges,4606.94,6258,
SUTURE 4.0 MONOSOFT P13,4202539,CDM,270,RC,,,OUTPATIENT,,,16.5,9.9,,14.03,85,,11.224,Percent of total billed charges,85% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,5.27,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,5.27,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.27,38,,16.72,percent of total billed charges,38% of total billed charges,6.6,40,,5.28,percent of total billed charges,40% of total billed charges,4607.94,6259,
SUTURE 4.0 MONOSOFT PS-2,4202540,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,35.568,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4608.94,6260,
SUTURE 4.0 POLYSORB P-1245,4202541,CDM,270,RC,,,OUTPATIENT,,,18.5,11.1,,15.73,85,,12.584,Percent of total billed charges,85% of total billed charges,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.25,50,,7.4,percent of total billed charges,50% of total billed charges,5.91,31.95,,4.728,percent of total billed charges,31.95% of total billed charges,5.91,31.95,,4.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.03,38,,33.44,percent of total billed charges,38% of total billed charges,7.4,40,,5.92,percent of total billed charges,40% of total billed charges,4609.94,6261,
SUTURE 4.0 POLYSORB TIES,4202542,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,18.24,percent of total billed charges,38% of total billed charges,10.8,40,,8.64,percent of total billed charges,40% of total billed charges,4610.94,6262,
SUTURE 4.0 VICRYL P13,4202543,CDM,270,RC,,,OUTPATIENT,,,23,13.8,,19.55,85,,15.64,Percent of total billed charges,85% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.74,38,,53.2,percent of total billed charges,38% of total billed charges,9.2,40,,7.36,percent of total billed charges,40% of total billed charges,4611.94,6263,
SUTURE 4.0 VICRYL SH V-20,4202544,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,42.56,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4612.94,6264,
SUTURE 5.0 MONOSOFT C1/C2,4202545,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,46.208,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4613.94,6265,
SUTURE 5.0 MONOSOFT P-13,4202546,CDM,270,RC,,,OUTPATIENT,,,16.5,9.9,,14.03,85,,11.224,Percent of total billed charges,85% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,5.27,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,5.27,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.27,38,,48.64,percent of total billed charges,38% of total billed charges,6.6,40,,5.28,percent of total billed charges,40% of total billed charges,4614.94,6266,
SUTURE 5.0 MONOSOFT PC-3 PC-11,4202547,CDM,270,RC,,,OUTPATIENT,,,21.5,12.9,,18.28,85,,14.624,Percent of total billed charges,85% of total billed charges,10.75,50,,8.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.75,50,,8.6,percent of total billed charges,50% of total billed charges,6.87,31.95,,5.496,percent of total billed charges,31.95% of total billed charges,6.87,31.95,,5.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.17,38,,48.64,percent of total billed charges,38% of total billed charges,8.6,40,,6.88,percent of total billed charges,40% of total billed charges,4615.94,6267,
SUTURE 5.0 VICRYL C-13,4202548,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,2.808,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,2.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,29.792,percent of total billed charges,38% of total billed charges,4.4,40,,3.52,percent of total billed charges,40% of total billed charges,4616.94,6268,
SUTURE 5.0 VICRYL P-13,4202549,CDM,270,RC,,,OUTPATIENT,,,17.5,10.5,,14.88,85,,11.904,Percent of total billed charges,85% of total billed charges,8.75,50,,7,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.75,50,,7,percent of total billed charges,50% of total billed charges,5.59,31.95,,4.472,percent of total billed charges,31.95% of total billed charges,5.59,31.95,,4.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.65,38,,48.336,percent of total billed charges,38% of total billed charges,7,40,,5.6,percent of total billed charges,40% of total billed charges,4617.94,6269,
SUTURE 6.0 MONOSOF C1 CV11,4202550,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,42.256,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4618.94,6270,
SUTURE 7.0 ETHILON P-6,4202551,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,10.944,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4619.94,6271,
SUTURE SURGIGUT GU-45,4202552,CDM,270,RC,,,OUTPATIENT,,,17.5,10.5,,14.88,85,,11.904,Percent of total billed charges,85% of total billed charges,8.75,50,,7,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.75,50,,7,percent of total billed charges,50% of total billed charges,5.59,31.95,,4.472,percent of total billed charges,31.95% of total billed charges,5.59,31.95,,4.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.65,38,,78.736,percent of total billed charges,38% of total billed charges,7,40,,5.6,percent of total billed charges,40% of total billed charges,4620.94,6272,
4.0 VICRYL PS-2,4202553,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,83.904,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4621.94,6273,
5.0 ETHILON,4202554,CDM,270,RC,,,OUTPATIENT,,,16.5,9.9,,14.03,85,,11.224,Percent of total billed charges,85% of total billed charges,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.25,50,,6.6,percent of total billed charges,50% of total billed charges,5.27,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,5.27,31.95,,4.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.27,38,,69.92,percent of total billed charges,38% of total billed charges,6.6,40,,5.28,percent of total billed charges,40% of total billed charges,4622.94,6274,
0 PERMA-HAND SILK KS,4202555,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,92.416,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4623.94,6275,
4.0 PERMA-HAND SILK,4202556,CDM,270,RC,,,OUTPATIENT,,,11.5,6.9,,9.78,85,,7.824,Percent of total billed charges,85% of total billed charges,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.75,50,,4.6,percent of total billed charges,50% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,3.67,31.95,,2.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.37,38,,103.36,percent of total billed charges,38% of total billed charges,4.6,40,,3.68,percent of total billed charges,40% of total billed charges,4624.94,6276,
3.0 ETHICON PS-2,4202557,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,103.36,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4625.94,6277,
4.0 POLYSORB P-12,4202558,CDM,270,RC,,,OUTPATIENT,,,23.5,14.1,,19.98,85,,15.984,Percent of total billed charges,85% of total billed charges,11.75,50,,9.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.75,50,,9.4,percent of total billed charges,50% of total billed charges,7.51,31.95,,6.008,percent of total billed charges,31.95% of total billed charges,7.51,31.95,,6.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.93,38,,28.576,percent of total billed charges,38% of total billed charges,9.4,40,,7.52,percent of total billed charges,40% of total billed charges,4626.94,6278,
OSTOMY WAFER NATURA 57MM,4202560,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4627.94,6279,
OSTOMY DRAINAGE POUCH TWO PIECE NATURA 2.75 W/FILTER,4202561,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4628.94,6280,
SKIN BARRIER WIPE NON-STERILE,4202562,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4629.94,6281,
OSTOMY ODOR ELIMINATOR 8OZ BOTTLE,4202563,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,57.152,percent of total billed charges,38% of total billed charges,16,40,,12.8,percent of total billed charges,40% of total billed charges,4630.94,6282,
MESH LARGE CIRCLE WITH STRAP 3.2: X 3.2,4202564,CDM,270,RC,,,OUTPATIENT,,,1700,1020,,1445,85,,1156,Percent of total billed charges,85% of total billed charges,850,50,,680,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,850,50,,680,percent of total billed charges,50% of total billed charges,543.15,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,543.15,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,646,38,,31.92,percent of total billed charges,38% of total billed charges,680,40,,544,percent of total billed charges,40% of total billed charges,4631.94,6283,
OPTIFOAM AG+ SILVER ANTIMICROBIAL WOUND DRESSING 4X 4,4202565,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,82.08,percent of total billed charges,38% of total billed charges,8.8,40,,7.04,percent of total billed charges,40% of total billed charges,4632.94,6284,
SUTURE 3.0 PROLENE P12,4202567,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,21.888,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4633.94,6285,
CUROS TIPS,4202570,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,34.96,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4634.94,6286,
DUAL ALCOHOL CAP STRIP OF 5,4202571,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,85.12,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4635.94,6287,
AVEA EXPIRATORY DISPOSABLE FILTER/WATER-TRAP,4202572,CDM,270,RC,,,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,2.872,percent of total billed charges,38% of total billed charges,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,4636.94,6288,
MESH 3X6'' RECTANGLE PROCEED,4202573,CDM,270,RC,,,OUTPATIENT,,,1397,838.2,,1187.45,85,,949.96,Percent of total billed charges,85% of total billed charges,698.5,50,,558.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,698.5,50,,558.8,percent of total billed charges,50% of total billed charges,446.34,31.95,,357.072,percent of total billed charges,31.95% of total billed charges,446.34,31.95,,357.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,530.86,38,,2.872,percent of total billed charges,38% of total billed charges,558.8,40,,447.04,percent of total billed charges,40% of total billed charges,4637.94,6289,
T.E.D. STOCKING XLARGE LONG,4202574,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,150.48,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4638.94,6290,
TROCAR BLADELESS STBLTY SLEEVE 12MM DIA 150MM XCEL,4202575,CDM,270,RC,,,OUTPATIENT,,,179,107.4,,152.15,85,,121.72,Percent of total billed charges,85% of total billed charges,89.5,50,,71.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,89.5,50,,71.6,percent of total billed charges,50% of total billed charges,57.19,31.95,,45.752,percent of total billed charges,31.95% of total billed charges,57.19,31.95,,45.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.02,38,,2.872,percent of total billed charges,38% of total billed charges,71.6,40,,57.28,percent of total billed charges,40% of total billed charges,4639.94,6291,
ECHOBLOCK PTDC30 NON-INSULATED SPINAL NEEDLE,4202576,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,150.48,percent of total billed charges,38% of total billed charges,11.2,40,,8.96,percent of total billed charges,40% of total billed charges,4640.94,6292,
Pelvic binder,4202577,CDM,270,RC,,,OUTPATIENT,,,645,387,,548.25,85,,438.6,Percent of total billed charges,85% of total billed charges,322.5,50,,258,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,322.5,50,,258,percent of total billed charges,50% of total billed charges,206.08,31.95,,164.864,percent of total billed charges,31.95% of total billed charges,206.08,31.95,,164.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,245.1,38,,3.648,percent of total billed charges,38% of total billed charges,258,40,,206.4,percent of total billed charges,40% of total billed charges,4641.94,6293,
SUTURE ETHILON 5-0 18  P-3,4202578,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,42.56,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4642.94,6294,
O-RING HEMORRHOID SEAL LIGATOR LF,4202579,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,36.48,percent of total billed charges,38% of total billed charges,0.8,40,,0.64,percent of total billed charges,40% of total billed charges,4643.94,6295,
ENDOSCOPIC CATHETER  CHANNEL RFA BARRX,4202580,CDM,270,RC,,,OUTPATIENT,,,3495,2097,,2970.75,85,,2376.6,Percent of total billed charges,85% of total billed charges,1747.5,50,,1398,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1747.5,50,,1398,percent of total billed charges,50% of total billed charges,1116.65,31.95,,893.32,percent of total billed charges,31.95% of total billed charges,1116.65,31.95,,893.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1328.1,38,,36.48,percent of total billed charges,38% of total billed charges,1398,40,,1118.4,percent of total billed charges,40% of total billed charges,4644.94,6296,
SHILEY TRACH CUFFLESS SIZE 4,4202581,CDM,270,RC,,,OUTPATIENT,,,77,46.2,,65.45,85,,52.36,Percent of total billed charges,85% of total billed charges,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,38.5,50,,30.8,percent of total billed charges,50% of total billed charges,24.6,31.95,,19.68,percent of total billed charges,31.95% of total billed charges,24.6,31.95,,19.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,29.26,38,,39.52,percent of total billed charges,38% of total billed charges,30.8,40,,24.64,percent of total billed charges,40% of total billed charges,4645.94,6297,
3000CC GLYCINE 1.5%,4202582,CDM,270,RC,,,OUTPATIENT,,,62,37.2,,52.7,85,,42.16,Percent of total billed charges,85% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31,50,,24.8,percent of total billed charges,50% of total billed charges,19.81,31.95,,15.848,percent of total billed charges,31.95% of total billed charges,19.81,31.95,,15.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.56,38,,60.8,percent of total billed charges,38% of total billed charges,24.8,40,,19.84,percent of total billed charges,40% of total billed charges,4646.94,6298,
UROLIFT DEVICES,4202584,CDM,278,RC,L8699,HCPCS,OUTPATIENT,,,2380,1428,,2499,105,,,case rate,pays based on 105% of threshold rate,1190,50,,952,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1190,50,,952,percent of total billed charges,50% of total billed charges,836.57,35.15,,669.256,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,904.4,38,,54.72,percent of total billed charges,38% of total billed charges,760.41,31.95,,608.328,percent of total billed charges,31.95% of total billed charges,4647.94,6299,
VISCERA RETAINER MEDIUM,4202585,CDM,270,RC,,,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.6,38,,59.28,percent of total billed charges,38% of total billed charges,28,40,,22.4,percent of total billed charges,40% of total billed charges,4648.94,6300,
UNNA BOOT GELLO CAST,4202586,CDM,270,RC,,,OUTPATIENT,,,14.5,8.7,,12.33,85,,9.864,Percent of total billed charges,85% of total billed charges,7.25,50,,5.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.25,50,,5.8,percent of total billed charges,50% of total billed charges,4.63,31.95,,3.704,percent of total billed charges,31.95% of total billed charges,4.63,31.95,,3.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.51,38,,38.608,percent of total billed charges,38% of total billed charges,5.8,40,,4.64,percent of total billed charges,40% of total billed charges,4649.94,6301,
DRESSING MEDIHONEY CALCIUM ALGINTE 2X2IN,4202587,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,16.72,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4650.94,6302,
NEEDLE COUNT BLOCK FOAM/MAGNETIC,4202588,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,74.48,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4651.94,6303,
TOURNIQUET TACTICAL COMBAT,4202589,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,51.68,percent of total billed charges,38% of total billed charges,14,40,,11.2,percent of total billed charges,40% of total billed charges,4652.94,6304,
CATHETER SILICONE 24FR 5CC,4202591,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,16.72,percent of total billed charges,38% of total billed charges,11.2,40,,8.96,percent of total billed charges,40% of total billed charges,4653.94,6305,
AQUACEL FOAM SACRAL DRESSING,4202592,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,16.72,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4654.94,6306,
GLIDESCOPE STATS GVL 3,4202594,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,27.36,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4655.94,6307,
STENT URETERAL POLARIS ULTRA 7/26,4202595,CDM,270,RC,,,OUTPATIENT,,,430,258,,365.5,85,,292.4,Percent of total billed charges,85% of total billed charges,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,14.592,percent of total billed charges,38% of total billed charges,172,40,,137.6,percent of total billed charges,40% of total billed charges,4656.94,6308,
COLD KNIFE DISPOSABLE,4202599,CDM,272,RC,,,OUTPATIENT,,,244,146.4,,207.4,85,,165.92,Percent of total billed charges,85% of total billed charges,122,50,,97.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,122,50,,97.6,percent of total billed charges,50% of total billed charges,77.96,31.95,,62.368,percent of total billed charges,31.95% of total billed charges,77.96,31.95,,62.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,92.72,38,,41.04,percent of total billed charges,38% of total billed charges,97.6,40,,78.08,percent of total billed charges,40% of total billed charges,4657.94,6309,
INFANT FEEDING TUBE 5FR,4202600,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,25.84,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4658.94,6310,
"POWERGLIDE MEDLINE CATHETER BASIC KIT 20G, 8CM",4202601,CDM,270,RC,,,OUTPATIENT,,,72,43.2,,61.2,85,,48.96,Percent of total billed charges,85% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36,50,,28.8,percent of total billed charges,50% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,58.976,percent of total billed charges,38% of total billed charges,28.8,40,,23.04,percent of total billed charges,40% of total billed charges,4659.94,6311,
POWERGLIDE MIDLINE CATHETER DRESSING CHANGE KIT WITH GUARDVA,4202602,CDM,278,RC,C1715,HCPCS,OUTPATIENT,,,25,15,,26.25,105,,,case rate,pays based on 105% of threshold rate,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,8.79,35.15,,7.032,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,51.68,percent of total billed charges,38% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,4660.94,6312,
TROCAR THORACIC CATHETER 12FR,4202603,CDM,270,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,26.448,percent of total billed charges,38% of total billed charges,18.8,40,,15.04,percent of total billed charges,40% of total billed charges,4661.94,6313,
BABY FOOD ENFAMIL GENTLE EASE CAN,4202604,CDM,270,RC,,,OUTPATIENT,,,27,16.2,,22.95,85,,18.36,Percent of total billed charges,85% of total billed charges,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13.5,50,,10.8,percent of total billed charges,50% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.26,38,,107.92,percent of total billed charges,38% of total billed charges,10.8,40,,8.64,percent of total billed charges,40% of total billed charges,4662.94,6314,
DRUG TEST ICUP 14 PANEL,4202606,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,9.12,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4663.94,6315,
PHILLIPS CATH FOLLOWER 16FR,4202609,CDM,270,RC,,,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,15.66,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,15.66,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.62,38,,9.12,percent of total billed charges,38% of total billed charges,19.6,40,,15.68,percent of total billed charges,40% of total billed charges,4664.94,6316,
STENT URETERAL POLARIS ULTRA 7/24,4202612,CDM,270,RC,,,OUTPATIENT,,,430,258,,365.5,85,,292.4,Percent of total billed charges,85% of total billed charges,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,19.76,percent of total billed charges,38% of total billed charges,172,40,,137.6,percent of total billed charges,40% of total billed charges,4665.94,6317,
SUTURE 6.0 MONOSOFT P12.,4202613,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,7.6,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4666.94,6318,
SUTURE 2.0 SOFSILK C-15,4202614,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,6.384,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4667.94,6319,
CLIP SURGICLIP L-13,4202615,CDM,270,RC,,,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,125,50,,100,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,125,50,,100,percent of total billed charges,50% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,38,,1.824,percent of total billed charges,38% of total billed charges,100,40,,80,percent of total billed charges,40% of total billed charges,4668.94,6320,
RELOAD-CURVED CUTTER STAPLER,4202616,CDM,270,RC,,,OUTPATIENT,,,388,232.8,,329.8,85,,263.84,Percent of total billed charges,85% of total billed charges,194,50,,155.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,194,50,,155.2,percent of total billed charges,50% of total billed charges,123.97,31.95,,99.176,percent of total billed charges,31.95% of total billed charges,123.97,31.95,,99.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.44,38,,9.12,percent of total billed charges,38% of total billed charges,155.2,40,,124.16,percent of total billed charges,40% of total billed charges,4669.94,6321,
CURVE CUTTER STAPLER,4202617,CDM,270,RC,,,OUTPATIENT,,,690,414,,586.5,85,,469.2,Percent of total billed charges,85% of total billed charges,345,50,,276,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,345,50,,276,percent of total billed charges,50% of total billed charges,220.46,31.95,,176.368,percent of total billed charges,31.95% of total billed charges,220.46,31.95,,176.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,262.2,38,,32.528,percent of total billed charges,38% of total billed charges,276,40,,220.8,percent of total billed charges,40% of total billed charges,4670.94,6322,
SUTURE RETENT BOLSTER 450 2.5CM,4202618,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,16.72,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4671.94,6323,
SUTURE ETHILON 2.0 GS-18,4202619,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,10.64,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4672.94,6324,
OSTOMY HIGH OUTPUT DRAINABLE POUCH 2.75'',4202620,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,10.64,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4673.94,6325,
OSTOMY FLANGE 2.75'',4202621,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,7.6,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4674.94,6326,
UMBILICAL TAPE COTTON,4202623,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,76,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4675.94,6327,
WEDGE BOLSTER FOAM 7X18'',4202624,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,76,percent of total billed charges,38% of total billed charges,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,4676.94,6328,
POSITIONER HEAD ADULT NON-CMPRS 9X8X4.5'',4202625,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,37.088,percent of total billed charges,38% of total billed charges,6.4,40,,5.12,percent of total billed charges,40% of total billed charges,4677.94,6329,
"BIOPSY INSTRUMENT, MAX-CORE 18GX25CM",4202626,CDM,270,RC,,,OUTPATIENT,,,222,133.2,,188.7,85,,150.96,Percent of total billed charges,85% of total billed charges,111,50,,88.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,111,50,,88.8,percent of total billed charges,50% of total billed charges,70.93,31.95,,56.744,percent of total billed charges,31.95% of total billed charges,70.93,31.95,,56.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,84.36,38,,37.088,percent of total billed charges,38% of total billed charges,88.8,40,,71.04,percent of total billed charges,40% of total billed charges,4678.94,6330,
TRIPLE LUMEN 7FR 16CM CENTRAL LINE TRAY,4202627,CDM,270,RC,,,OUTPATIENT,,,351,210.6,,298.35,85,,238.68,Percent of total billed charges,85% of total billed charges,175.5,50,,140.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,175.5,50,,140.4,percent of total billed charges,50% of total billed charges,112.14,31.95,,89.712,percent of total billed charges,31.95% of total billed charges,112.14,31.95,,89.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133.38,38,,23.408,percent of total billed charges,38% of total billed charges,140.4,40,,112.32,percent of total billed charges,40% of total billed charges,4679.94,6331,
INDWELLING SLIT  CATHETER SET (ORTHO),4202628,CDM,270,RC,,,OUTPATIENT,,,347,208.2,,294.95,85,,235.96,Percent of total billed charges,85% of total billed charges,173.5,50,,138.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,173.5,50,,138.8,percent of total billed charges,50% of total billed charges,110.87,31.95,,88.696,percent of total billed charges,31.95% of total billed charges,110.87,31.95,,88.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.86,38,,34.048,percent of total billed charges,38% of total billed charges,138.8,40,,111.04,percent of total billed charges,40% of total billed charges,4680.94,6332,
DIGITAL FLEXIBLE URETEROSCOPE STANDARD DEFLECTION SINGLE USE,4202629,CDM,270,RC,,,OUTPATIENT,,,4500,2700,,3825,85,,3060,Percent of total billed charges,85% of total billed charges,2250,50,,1800,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2250,50,,1800,percent of total billed charges,50% of total billed charges,1437.75,31.95,,1150.2,percent of total billed charges,31.95% of total billed charges,1437.75,31.95,,1150.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1710,38,,51.072,percent of total billed charges,38% of total billed charges,1800,40,,1440,percent of total billed charges,40% of total billed charges,4681.94,6333,
DIGITAL FLEXIBLE URETEROSCOPE REVERSE DEFLECTION SINGLE USE,4202630,CDM,270,RC,,,OUTPATIENT,,,4500,2700,,3825,85,,3060,Percent of total billed charges,85% of total billed charges,2250,50,,1800,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2250,50,,1800,percent of total billed charges,50% of total billed charges,1437.75,31.95,,1150.2,percent of total billed charges,31.95% of total billed charges,1437.75,31.95,,1150.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1710,38,,89.68,percent of total billed charges,38% of total billed charges,1800,40,,1440,percent of total billed charges,40% of total billed charges,4682.94,6334,
CAST ORTHO GLASS 3IN X 15FT,4202631,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,45.6,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4683.94,6335,
TIES 0 SOFSILK,4202632,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,4.56,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4684.94,6336,
TROCAR THORACIC CATHETER 8FR,4202633,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,60.192,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4685.94,6337,
BENZOIN TINCTURE 0.6ML SWAB AMPULE,4202634,CDM,270,RC,,,OUTPATIENT,,,1,0.6,,0.85,85,,0.68,Percent of total billed charges,85% of total billed charges,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.5,50,,0.4,percent of total billed charges,50% of total billed charges,0.32,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,0.32,31.95,,0.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.38,38,,15.2,percent of total billed charges,38% of total billed charges,0.4,40,,0.32,percent of total billed charges,40% of total billed charges,4686.94,6338,
GLOVE SURGICAL 9  POWDER FREE,4202635,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,24.32,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4687.94,6339,
BLOOD PRESSURE CUFF W/BULB DISPOSABLE INFANT,4202636,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,30.4,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4688.94,6340,
QUICK STIC PRESSURE MONITOR SET (USED WITH COMPARTMENT INSTR,4202639,CDM,270,RC,,,OUTPATIENT,,,312,187.2,,265.2,85,,212.16,Percent of total billed charges,85% of total billed charges,156,50,,124.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,156,50,,124.8,percent of total billed charges,50% of total billed charges,99.68,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,99.68,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,118.56,38,,46.512,percent of total billed charges,38% of total billed charges,124.8,40,,99.84,percent of total billed charges,40% of total billed charges,4689.94,6341,
NEEDLE BLOCK ULTRAPLEX 20 GA. X 4 IN. NON-INSULATED AND EXTE,4202640,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,65.664,percent of total billed charges,38% of total billed charges,16,40,,12.8,percent of total billed charges,40% of total billed charges,4690.94,6342,
VERTICAL PATIENT ISOLATION DRP,4202644,CDM,270,RC,,,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,11.82,31.95,,9.456,percent of total billed charges,31.95% of total billed charges,11.82,31.95,,9.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.06,38,,27.36,percent of total billed charges,38% of total billed charges,14.8,40,,11.84,percent of total billed charges,40% of total billed charges,4691.94,6343,
CAST TAPE 3''X4YDS FIBERGLASS WHITE LF,4202645,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,25.84,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4692.94,6344,
DRESSING COTTON ROBERT JONES 12:X11FT STERILE,4202646,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,71.44,percent of total billed charges,38% of total billed charges,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,4693.94,6345,
CAST TAPE 4''X4YDS FIBERGLASS WHITE LF,4202647,CDM,270,RC,,,OUTPATIENT,,,11,6.6,,9.35,85,,7.48,Percent of total billed charges,85% of total billed charges,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.5,50,,4.4,percent of total billed charges,50% of total billed charges,3.51,31.95,,2.808,percent of total billed charges,31.95% of total billed charges,3.51,31.95,,2.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.18,38,,53.2,percent of total billed charges,38% of total billed charges,4.4,40,,3.52,percent of total billed charges,40% of total billed charges,4694.94,6346,
DOUBLE ELASTIC BANDAGE 4''X11YDS.,4202648,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,77.52,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4695.94,6347,
ZIP STICK PLASTIC 19'',4202649,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,60.8,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4696.94,6348,
PLASTER ROLLS 4X5YD EXTRA-FAST PLASTER GREEN LABEL,4202651,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,69.92,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4697.94,6349,
PLASTER ROLL 3X3YD SPECIALIST EXTRA-FAST PLASTER GREEN LABEL,4202652,CDM,270,RC,,,OUTPATIENT,,,3,1.8,,2.55,85,,2.04,Percent of total billed charges,85% of total billed charges,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.5,50,,1.2,percent of total billed charges,50% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.14,38,,69.92,percent of total billed charges,38% of total billed charges,1.2,40,,0.96,percent of total billed charges,40% of total billed charges,4698.94,6350,
TAPE CAST 3INX4YD PLUS WHITE,4202653,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,25.84,percent of total billed charges,38% of total billed charges,5.2,40,,4.16,percent of total billed charges,40% of total billed charges,4699.94,6351,
12 X 3.5 PNEUMATIC TOURNIQUET GREEN,4202654,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,10.992,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,10.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,33.44,percent of total billed charges,38% of total billed charges,17.2,40,,13.76,percent of total billed charges,40% of total billed charges,4700.94,6352,
18 X 4 PNEUMATIC TOURNIQUET RED,4202655,CDM,270,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,51.68,percent of total billed charges,38% of total billed charges,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,4701.94,6353,
24 X 4 PNEUMATIC TOURNIQUET YELLOW,4202656,CDM,270,RC,,,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.14,38,,69.92,percent of total billed charges,38% of total billed charges,21.2,40,,16.96,percent of total billed charges,40% of total billed charges,4702.94,6354,
30 X 4 PNEUMATIC TOURNIQUET ROYAL BLUE,4202657,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,42.56,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4703.94,6355,
34 X 4 PNEUMATIC TOURNIQUET PURPLE,4202658,CDM,270,RC,,,OUTPATIENT,,,61,36.6,,51.85,85,,41.48,Percent of total billed charges,85% of total billed charges,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,19.49,31.95,,15.592,percent of total billed charges,31.95% of total billed charges,19.49,31.95,,15.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.18,38,,24.32,percent of total billed charges,38% of total billed charges,24.4,40,,19.52,percent of total billed charges,40% of total billed charges,4704.94,6356,
44 X 4 PNEUMATIC TOURNIQUET NAVY BLUE,4202659,CDM,270,RC,,,OUTPATIENT,,,67,40.2,,56.95,85,,45.56,Percent of total billed charges,85% of total billed charges,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33.5,50,,26.8,percent of total billed charges,50% of total billed charges,21.41,31.95,,17.128,percent of total billed charges,31.95% of total billed charges,21.41,31.95,,17.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.46,38,,30.4,percent of total billed charges,38% of total billed charges,26.8,40,,21.44,percent of total billed charges,40% of total billed charges,4705.94,6357,
ANASCPT WOUND CLEANER 12 OZ. SPRAY BOTTLE,4202660,CDM,270,RC,,,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,46.512,percent of total billed charges,38% of total billed charges,9.6,40,,7.68,percent of total billed charges,40% of total billed charges,4706.94,6358,
IODOFLEX DRESSING 1.5X2.3/8 CADEXOMER IODINE,4202661,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,65.664,percent of total billed charges,38% of total billed charges,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,4707.94,6359,
HYDRAFERA BLUE DRESSING 2.5X2.5 W/O BORDERS,4202662,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,29.792,percent of total billed charges,38% of total billed charges,6.4,40,,5.12,percent of total billed charges,40% of total billed charges,4708.94,6360,
CALCIUM ALGINATE DRESSING W/ SILVER RESTORE 1X12 ROPE,4202663,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,45.296,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4709.94,6361,
2 LAYER  COMPRESSION BANDAGE SYSTEM COBAN 2.9YDS X 4'',4202664,CDM,270,RC,,,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,20,percent of total billed charges,50% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,77.52,percent of total billed charges,38% of total billed charges,20,40,,16,percent of total billed charges,40% of total billed charges,4710.94,6362,
DEBRIDEMENT DEBRISOFT PAD,4202665,CDM,270,RC,,,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.38,38,,100.016,percent of total billed charges,38% of total billed charges,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,4711.94,6363,
CURETTE DERMAL 2MM DISPOSABLE,4202666,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,29.792,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4712.94,6364,
CURETTE DERMAL 7MM DISPOSABLE,4202667,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,45.296,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4713.94,6365,
CURETTE DERMAL 4MM DISPOSABLE,4202668,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,77.52,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4714.94,6366,
CURETTE DERMAL 5MM DISPOSABLE,4202670,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,100.016,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4715.94,6367,
BANDAGING SYSTEM FOUR LAYER PROFORE,4202671,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,51.984,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4716.94,6368,
HYDROFERA BLUE DRESSING 4''X5'',4202672,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,60.8,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4717.94,6369,
SEAL EAKIN 2'' WAFER BARRIER,4202674,CDM,270,RC,,,OUTPATIENT,,,1.98,1.188,,1.68,85,,1.344,Percent of total billed charges,85% of total billed charges,0.99,50,,0.792,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,0.99,50,,0.792,percent of total billed charges,50% of total billed charges,0.63,31.95,,0.504,percent of total billed charges,31.95% of total billed charges,0.63,31.95,,0.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.75,38,,68.704,percent of total billed charges,38% of total billed charges,0.79,40,,0.632,percent of total billed charges,40% of total billed charges,4718.94,6370,
PLASTER ROLLS BANDAGE 2X3YD SPECIALIST EXTRA-FAST GREEN LABE,4202675,CDM,270,RC,,,OUTPATIENT,,,2,1.2,,1.7,85,,1.36,Percent of total billed charges,85% of total billed charges,1,50,,0.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1,50,,0.8,percent of total billed charges,50% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,0.64,31.95,,0.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,0.76,38,,91.2,percent of total billed charges,38% of total billed charges,0.8,40,,0.64,percent of total billed charges,40% of total billed charges,4719.94,6371,
PLASTER SPLINT GYPSONA X-FAST 3 INCH X 15 INCH,4202676,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,101.84,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4720.94,6372,
PLASTER SPLINT 4''X15'' SPECIALIST EXTRA FAST PLASTER GREEN LA,4202677,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,64.752,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4721.94,6373,
PLASTER SPLINT 5''X30'' SPECIALIST EXTRA FAST PLASTER GREEN LA,4202678,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,18.848,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4722.94,6374,
CLINCHER ARTICULATING 5MM SINGLE USE,4202682,CDM,270,RC,,,OUTPATIENT,,,450,270,,382.5,85,,306,Percent of total billed charges,85% of total billed charges,225,50,,180,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,225,50,,180,percent of total billed charges,50% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,171,38,,76,percent of total billed charges,38% of total billed charges,180,40,,144,percent of total billed charges,40% of total billed charges,4723.94,6375,
KNEE ARTHROSCOPY IV,4202683,CDM,270,RC,,,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.3,38,,152,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,4724.94,6376,
SUTURE 0 VICRYL OS-6,4202685,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,364.8,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4725.94,6377,
SUTURE 0 VICRYL OS-4,4202686,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,148.352,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4726.94,6378,
SUTURE ETHIBOND 5.0 GREEN V-40,4202687,CDM,270,RC,,,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,20,percent of total billed charges,50% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,155.04,percent of total billed charges,38% of total billed charges,20,40,,16,percent of total billed charges,40% of total billed charges,4727.94,6379,
SUTURE 2.0 VICRYL PS-2 P-12,4202688,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,193.04,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4728.94,6380,
GLOVE SURGEON 9.0 BIOGEL,4202690,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,182.4,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4729.94,6381,
SHOECOVER HIGHTOP X-LARGE IMPERVIOUS,4202697,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,2.872,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4730.94,6382,
SILSPORT FLEXIBLE PORT 5MM-12MM,4202699,CDM,270,RC,,,OUTPATIENT,,,813,487.8,,691.05,85,,552.84,Percent of total billed charges,85% of total billed charges,406.5,50,,325.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,406.5,50,,325.2,percent of total billed charges,50% of total billed charges,259.75,31.95,,207.8,percent of total billed charges,31.95% of total billed charges,259.75,31.95,,207.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,308.94,38,,6.08,percent of total billed charges,38% of total billed charges,325.2,40,,260.16,percent of total billed charges,40% of total billed charges,4731.94,6383,
HEAD POSITIONER UNIVERSAL DISPOSABLE,4202700,CDM,270,RC,,,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,20,percent of total billed charges,50% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,15.2,percent of total billed charges,38% of total billed charges,20,40,,16,percent of total billed charges,40% of total billed charges,4732.94,6384,
FOAM CUSION INSERT FOR LEG HOLDER,4202701,CDM,270,RC,,,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,40,50,,32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40,50,,32,percent of total billed charges,50% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,32,40,,25.6,percent of total billed charges,40% of total billed charges,4733.94,6385,
COBAN 4'' STERILE,4202702,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,2.128,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4734.94,6386,
SPEEDGUIDE FOR 3.5MM T10 (L = 30MM),4202704,CDM,272,RC,,,OUTPATIENT,,,1010,606,,858.5,85,,686.8,Percent of total billed charges,85% of total billed charges,505,50,,404,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,505,50,,404,percent of total billed charges,50% of total billed charges,322.7,31.95,,258.16,percent of total billed charges,31.95% of total billed charges,322.7,31.95,,258.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,383.8,38,,307.04,percent of total billed charges,38% of total billed charges,404,40,,323.2,percent of total billed charges,40% of total billed charges,4735.94,6387,
ESMARK BANDAGE 6'' X 4YDS.,4202707,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,6.384,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4736.94,6388,
SUTURE VICRYL CTD CT-2,4202708,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4737.94,6389,
SUPERIOR PLATE - DECREASED CURVATURE VARIAX CLAVICLE 7 HOLE,4202709,CDM,270,RC,,,OUTPATIENT,,,1895,1137,,1610.75,85,,1288.6,Percent of total billed charges,85% of total billed charges,947.5,50,,758,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,947.5,50,,758,percent of total billed charges,50% of total billed charges,605.45,31.95,,484.36,percent of total billed charges,31.95% of total billed charges,605.45,31.95,,484.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,720.1,38,,576.08,percent of total billed charges,38% of total billed charges,758,40,,606.4,percent of total billed charges,40% of total billed charges,4738.94,6390,
COBAN 2 LAYER LITE COMPRESSION SYSTEM,4202710,CDM,270,RC,,,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,15.6,40,,12.48,percent of total billed charges,40% of total billed charges,4739.94,6391,
CROSSFLOW INTEGRATED CASSETTE TUBING,4202711,CDM,270,RC,,,OUTPATIENT,,,345,207,,293.25,85,,234.6,Percent of total billed charges,85% of total billed charges,172.5,50,,138,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,172.5,50,,138,percent of total billed charges,50% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.1,38,,104.88,percent of total billed charges,38% of total billed charges,138,40,,110.4,percent of total billed charges,40% of total billed charges,4740.94,6392,
3.5 AGG. MAX SHAVER BLADE,4202712,CDM,270,RC,,,OUTPATIENT,,,260,156,,221,85,,176.8,Percent of total billed charges,85% of total billed charges,130,50,,104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,130,50,,104,percent of total billed charges,50% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,98.8,38,,79.04,percent of total billed charges,38% of total billed charges,104,40,,83.2,percent of total billed charges,40% of total billed charges,4741.94,6393,
MEPILEX 4X4 BORDER ADHESIVE,4202713,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,2.736,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4742.94,6394,
MEPILEX 6X6 BORDER ADHESIVE,4202714,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,4.56,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,4743.94,6395,
1.2CC VITOSS,4202715,CDM,270,RC,,,OUTPATIENT,,,1020,612,,867,85,,693.6,Percent of total billed charges,85% of total billed charges,510,50,,408,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,510,50,,408,percent of total billed charges,50% of total billed charges,325.89,31.95,,260.712,percent of total billed charges,31.95% of total billed charges,325.89,31.95,,260.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,387.6,38,,310.08,percent of total billed charges,38% of total billed charges,408,40,,326.4,percent of total billed charges,40% of total billed charges,4744.94,6396,
"OVERDRILL 3.5 AO, DIA 2.7MM X 122MM",4202717,CDM,270,RC,,,OUTPATIENT,,,217,130.2,,184.45,85,,147.56,Percent of total billed charges,85% of total billed charges,108.5,50,,86.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,108.5,50,,86.8,percent of total billed charges,50% of total billed charges,69.33,31.95,,55.464,percent of total billed charges,31.95% of total billed charges,69.33,31.95,,55.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,82.46,38,,65.968,percent of total billed charges,38% of total billed charges,86.8,40,,69.44,percent of total billed charges,40% of total billed charges,4745.94,6397,
"VARIAX STRAIGHT PLATE, 6 HOLE",4202718,CDM,270,RC,,,OUTPATIENT,,,1096,657.6,,931.6,85,,745.28,Percent of total billed charges,85% of total billed charges,548,50,,438.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,548,50,,438.4,percent of total billed charges,50% of total billed charges,350.17,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,350.17,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,416.48,38,,333.184,percent of total billed charges,38% of total billed charges,438.4,40,,350.72,percent of total billed charges,40% of total billed charges,4746.94,6398,
VARIAX STRAIGHT PLATE 3 HOLE,4202719,CDM,270,RC,,,OUTPATIENT,,,1096,657.6,,931.6,85,,745.28,Percent of total billed charges,85% of total billed charges,548,50,,438.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,548,50,,438.4,percent of total billed charges,50% of total billed charges,350.17,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,350.17,31.95,,280.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,416.48,38,,333.184,percent of total billed charges,38% of total billed charges,438.4,40,,350.72,percent of total billed charges,40% of total billed charges,4747.94,6399,
SLEEVE ONE SIZE LF STERILE,4202720,CDM,270,RC,,,OUTPATIENT,,,3.69,2.214,,3.14,85,,2.512,Percent of total billed charges,85% of total billed charges,1.85,50,,1.48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1.85,50,,1.48,percent of total billed charges,50% of total billed charges,1.18,31.95,,0.944,percent of total billed charges,31.95% of total billed charges,1.18,31.95,,0.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.4,38,,1.12,percent of total billed charges,38% of total billed charges,1.48,40,,1.184,percent of total billed charges,40% of total billed charges,4748.94,6400,
SUTURE 1 VICRYL CT1 27'' UNDYED,4202721,CDM,270,RC,,,OUTPATIENT,,,4.35,2.61,,3.7,85,,2.96,Percent of total billed charges,85% of total billed charges,2.18,50,,1.744,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.18,50,,1.744,percent of total billed charges,50% of total billed charges,1.39,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,1.39,31.95,,1.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.65,38,,1.32,percent of total billed charges,38% of total billed charges,1.74,40,,1.392,percent of total billed charges,40% of total billed charges,4749.94,6401,
QWICK DRESSING NON-ADHESIVE 4.25X4,4202723,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,5.168,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4750.94,6402,
OPTIFOAM DRESSING GENTLE BORDER 4X4,4202724,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,2.432,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4751.94,6403,
SUTURE 4.0 VICRYL PS-2 P-12 27'' UNDYED,4202725,CDM,270,RC,,,OUTPATIENT,,,10.25,6.15,,8.71,85,,6.968,Percent of total billed charges,85% of total billed charges,5.13,50,,4.104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5.13,50,,4.104,percent of total billed charges,50% of total billed charges,3.27,31.95,,2.616,percent of total billed charges,31.95% of total billed charges,3.27,31.95,,2.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.9,38,,3.12,percent of total billed charges,38% of total billed charges,4.1,40,,3.28,percent of total billed charges,40% of total billed charges,4752.94,6404,
Laparoscopic/Cholecystectomy Drape w/Inst Pouch,4202726,CDM,270,RC,,,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.28,38,,17.024,percent of total billed charges,38% of total billed charges,22.4,40,,17.92,percent of total billed charges,40% of total billed charges,4753.94,6405,
STAX SIZE 1 FINGER SPLINT,4202727,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4754.94,6406,
STAX SIZE 2 FINGER SPLINT,4202728,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4755.94,6407,
STAX SIZE 3 FINGER SPLINT,4202729,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4756.94,6408,
STAX SIZE 4 FINGER SPLINT,4202730,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4757.94,6409,
STAX SIZE 5 FINGER SPLINT,4202731,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4758.94,6410,
STAX SIZE 5.5 FINGER SPLINT,4202732,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4759.94,6411,
STAX SIZE 6 FINGER SPLINT,4202733,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4760.94,6412,
STAX SIZE 7 FINGER SPLINT,4202734,CDM,272,RC,Q4049,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,2.57,100,,,fee schedule,100% of CMS custom fee schedule,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,4761.94,6413,
"OMEGA PLUS 2.8MM THREADED TIP GUIDE PIN, 230MM",4202740,CDM,270,RC,,,OUTPATIENT,,,99,59.4,,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.62,38,,30.096,percent of total billed charges,38% of total billed charges,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,4762.94,6414,
"OMEGA3 STANDARD BARREL HIP PLATE, KEYLESS 140?, 2 HOLES",4202741,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,994,596.4,,1043.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,349.39,35.15,,279.512,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,377.72,38,,302.176,percent of total billed charges,38% of total billed charges,317.58,31.95,,254.064,percent of total billed charges,31.95% of total billed charges,4763.94,6415,
OMEGA PLUS LAG SCREW 90MM,4202742,CDM,270,RC,,,OUTPATIENT,,,416,249.6,,353.6,85,,282.88,Percent of total billed charges,85% of total billed charges,208,50,,166.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,208,50,,166.4,percent of total billed charges,50% of total billed charges,132.91,31.95,,106.328,percent of total billed charges,31.95% of total billed charges,132.91,31.95,,106.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,158.08,38,,126.464,percent of total billed charges,38% of total billed charges,166.4,40,,133.12,percent of total billed charges,40% of total billed charges,4764.94,6416,
SELF TAP CORTICAL SCREW 4.5X36MM,4202744,CDM,270,RC,,,OUTPATIENT,,,43,25.8,,36.55,85,,29.24,Percent of total billed charges,85% of total billed charges,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21.5,50,,17.2,percent of total billed charges,50% of total billed charges,13.74,31.95,,10.992,percent of total billed charges,31.95% of total billed charges,13.74,31.95,,10.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.34,38,,13.072,percent of total billed charges,38% of total billed charges,17.2,40,,13.76,percent of total billed charges,40% of total billed charges,4765.94,6417,
SELF TAP CORTICAL SCREW 4.5X38MM,4202745,CDM,270,RC,,,OUTPATIENT,,,72,43.2,,61.2,85,,48.96,Percent of total billed charges,85% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36,50,,28.8,percent of total billed charges,50% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,28.8,40,,23.04,percent of total billed charges,40% of total billed charges,4766.94,6418,
ASNIS III THREADED GUIDE WIRE DIA 3.2 X 300MM,4202746,CDM,270,RC,,,OUTPATIENT,,,264,158.4,,224.4,85,,179.52,Percent of total billed charges,85% of total billed charges,132,50,,105.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,132,50,,105.6,percent of total billed charges,50% of total billed charges,84.35,31.95,,67.48,percent of total billed charges,31.95% of total billed charges,84.35,31.95,,67.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,100.32,38,,80.256,percent of total billed charges,38% of total billed charges,105.6,40,,84.48,percent of total billed charges,40% of total billed charges,4767.94,6419,
TI ASNIS III CANNULATED SCR 6.5X95MM,4202747,CDM,270,RC,,,OUTPATIENT,,,460,276,,391,85,,312.8,Percent of total billed charges,85% of total billed charges,230,50,,184,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,230,50,,184,percent of total billed charges,50% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,174.8,38,,139.84,percent of total billed charges,38% of total billed charges,184,40,,147.2,percent of total billed charges,40% of total billed charges,4768.94,6420,
TI ASNIS III CANNULATED SCR 6.5X90MM,4202748,CDM,270,RC,,,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,175,50,,140,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,175,50,,140,percent of total billed charges,50% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,140,40,,112,percent of total billed charges,40% of total billed charges,4769.94,6421,
TI ASNIS III CANNULATED SCR 6.5X85MM,4202749,CDM,270,RC,,,OUTPATIENT,,,459,275.4,,390.15,85,,312.12,Percent of total billed charges,85% of total billed charges,229.5,50,,183.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,229.5,50,,183.6,percent of total billed charges,50% of total billed charges,146.65,31.95,,117.32,percent of total billed charges,31.95% of total billed charges,146.65,31.95,,117.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,174.42,38,,139.536,percent of total billed charges,38% of total billed charges,183.6,40,,146.88,percent of total billed charges,40% of total billed charges,4770.94,6422,
COMPRESSION SCREW,4202750,CDM,270,RC,,,OUTPATIENT,,,104,62.4,,88.4,85,,70.72,Percent of total billed charges,85% of total billed charges,52,50,,41.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52,50,,41.6,percent of total billed charges,50% of total billed charges,33.23,31.95,,26.584,percent of total billed charges,31.95% of total billed charges,33.23,31.95,,26.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.52,38,,31.616,percent of total billed charges,38% of total billed charges,41.6,40,,33.28,percent of total billed charges,40% of total billed charges,4771.94,6423,
CUTIMED OFF-LOADER TOTAL CONTACT CASTING 1KIT,4202751,CDM,270,RC,,,OUTPATIENT,,,117,70.2,,99.45,85,,79.56,Percent of total billed charges,85% of total billed charges,58.5,50,,46.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,58.5,50,,46.8,percent of total billed charges,50% of total billed charges,37.38,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,37.38,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.46,38,,35.568,percent of total billed charges,38% of total billed charges,46.8,40,,37.44,percent of total billed charges,40% of total billed charges,4772.94,6424,
K-WIRE WITH DRILL TIP ?2.0 X 234MM,4202754,CDM,270,RC,,,OUTPATIENT,,,137,82.2,,116.45,85,,93.16,Percent of total billed charges,85% of total billed charges,68.5,50,,54.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,68.5,50,,54.8,percent of total billed charges,50% of total billed charges,43.77,31.95,,35.016,percent of total billed charges,31.95% of total billed charges,43.77,31.95,,35.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,52.06,38,,41.648,percent of total billed charges,38% of total billed charges,54.8,40,,43.84,percent of total billed charges,40% of total billed charges,4773.94,6425,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L22MM,4202755,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,282,169.2,,296.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,99.12,35.15,,79.296,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,107.16,38,,85.728,percent of total billed charges,38% of total billed charges,90.1,31.95,,72.08,percent of total billed charges,31.95% of total billed charges,4774.94,6426,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L30MM,4202756,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,282,169.2,,296.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,99.12,35.15,,79.296,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,107.16,38,,85.728,percent of total billed charges,38% of total billed charges,90.1,31.95,,72.08,percent of total billed charges,31.95% of total billed charges,4775.94,6427,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L34MM,4202757,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,4776.94,6428,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L42MM,4202758,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,4777.94,6429,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L44MM,4202759,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,282,169.2,,296.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,99.12,35.15,,79.296,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,107.16,38,,85.728,percent of total billed charges,38% of total billed charges,90.1,31.95,,72.08,percent of total billed charges,31.95% of total billed charges,4778.94,6430,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L46MM,4202760,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,4779.94,6431,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L48MM,4202761,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,290,174,,304.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,101.94,35.15,,81.552,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.2,38,,88.16,percent of total billed charges,38% of total billed charges,92.66,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,4780.94,6432,
AXSOS 3 TI3.5MM CORTEX TI SCREW?3.5MM / L34MM,4202762,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,45,27,,47.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.82,35.15,,12.656,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,4781.94,6433,
4MM CANCELLOUS TI SCREW 4.0MM / L48MM / FULL THREAD,4202763,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,65,39,,68.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.85,35.15,,18.28,percent of total billed charges,35.15% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,4782.94,6434,
4MM CANCELLOUS TI SCREW 4.0MM / L36MM / FULL THREAD,4202764,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,65,39,,68.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.85,35.15,,18.28,percent of total billed charges,35.15% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,4783.94,6435,
4MM CANCELLOUS TI SCREW 4.0MM / L42MM / FULL THREAD,4202765,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,65,39,,68.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.85,35.15,,18.28,percent of total billed charges,35.15% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,4784.94,6436,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 4 HOLE / L9,4202766,CDM,270,RC,,,OUTPATIENT,,,2903,1741.8,,2467.55,85,,1974.04,Percent of total billed charges,85% of total billed charges,1451.5,50,,1161.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1451.5,50,,1161.2,percent of total billed charges,50% of total billed charges,927.51,31.95,,742.008,percent of total billed charges,31.95% of total billed charges,927.51,31.95,,742.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1103.14,38,,882.512,percent of total billed charges,38% of total billed charges,1161.2,40,,928.96,percent of total billed charges,40% of total billed charges,4785.94,6437,
5CC VITOSS,4202767,CDM,270,RC,,,OUTPATIENT,,,3270,1962,,2779.5,85,,2223.6,Percent of total billed charges,85% of total billed charges,1635,50,,1308,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1635,50,,1308,percent of total billed charges,50% of total billed charges,1044.77,31.95,,835.816,percent of total billed charges,31.95% of total billed charges,1044.77,31.95,,835.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1242.6,38,,994.08,percent of total billed charges,38% of total billed charges,1308,40,,1046.4,percent of total billed charges,40% of total billed charges,4786.94,6438,
SUTURE RETRIEVER HEWSON 10.1'',4202768,CDM,270,RC,,,OUTPATIENT,,,494,296.4,,419.9,85,,335.92,Percent of total billed charges,85% of total billed charges,247,50,,197.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,247,50,,197.6,percent of total billed charges,50% of total billed charges,157.83,31.95,,126.264,percent of total billed charges,31.95% of total billed charges,157.83,31.95,,126.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,187.72,38,,150.176,percent of total billed charges,38% of total billed charges,197.6,40,,158.08,percent of total billed charges,40% of total billed charges,4787.94,6439,
"SUTURE 4.0 ETHILON P-3, P-13",4202770,CDM,270,RC,,,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,4,40,,3.2,percent of total billed charges,40% of total billed charges,4788.94,6440,
SPEEDGUIDE FOR 2.7MM T10 (L = 30MM),4202773,CDM,270,RC,,,OUTPATIENT,,,538,322.8,,457.3,85,,365.84,Percent of total billed charges,85% of total billed charges,269,50,,215.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,269,50,,215.2,percent of total billed charges,50% of total billed charges,171.89,31.95,,137.512,percent of total billed charges,31.95% of total billed charges,171.89,31.95,,137.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,204.44,38,,163.552,percent of total billed charges,38% of total billed charges,215.2,40,,172.16,percent of total billed charges,40% of total billed charges,4789.94,6441,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 3 HOLE / L8,4202774,CDM,270,RC,,,OUTPATIENT,,,5805,3483,,4934.25,85,,3947.4,Percent of total billed charges,85% of total billed charges,2902.5,50,,2322,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2902.5,50,,2322,percent of total billed charges,50% of total billed charges,1854.7,31.95,,1483.76,percent of total billed charges,31.95% of total billed charges,1854.7,31.95,,1483.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2205.9,38,,1764.72,percent of total billed charges,38% of total billed charges,2322,40,,1857.6,percent of total billed charges,40% of total billed charges,4790.94,6442,
AXSOS 3 TI3.5MM CORTEX TI SCREW?3.5MM / L38MM,4202775,CDM,270,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4791.94,6443,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L26MM,4202777,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,4792.94,6444,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L28MM,4202779,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,290,174,,304.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,101.94,35.15,,81.552,percent of total billed charges,35.15% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.2,38,,88.16,percent of total billed charges,38% of total billed charges,92.66,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,4793.94,6445,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L36MM,4202780,CDM,270,RC,,,OUTPATIENT,,,389,233.4,,330.65,85,,264.52,Percent of total billed charges,85% of total billed charges,194.5,50,,155.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,194.5,50,,155.6,percent of total billed charges,50% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,155.6,40,,124.48,percent of total billed charges,40% of total billed charges,4794.94,6446,
"IMPLANT DELIVERY SYSTEM, BIOCOMPOSITE DISTAL BICEPS REPAIR",4202781,CDM,270,RC,,,OUTPATIENT,,,3300,1980,,2805,85,,2244,Percent of total billed charges,85% of total billed charges,1650,50,,1320,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1650,50,,1320,percent of total billed charges,50% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1254,38,,1003.2,percent of total billed charges,38% of total billed charges,1320,40,,1056,percent of total billed charges,40% of total billed charges,4795.94,6447,
"SUTURELASSO, 45 DEGREE CURVE RIGHT",4202782,CDM,270,RC,,,OUTPATIENT,,,420,252,,357,85,,285.6,Percent of total billed charges,85% of total billed charges,210,50,,168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,210,50,,168,percent of total billed charges,50% of total billed charges,134.19,31.95,,107.352,percent of total billed charges,31.95% of total billed charges,134.19,31.95,,107.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,159.6,38,,127.68,percent of total billed charges,38% of total billed charges,168,40,,134.4,percent of total billed charges,40% of total billed charges,4796.94,6448,
"SUTURELASSO, 90 DEGREE STRAIGHT",4202783,CDM,270,RC,,,OUTPATIENT,,,420,252,,357,85,,285.6,Percent of total billed charges,85% of total billed charges,210,50,,168,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,210,50,,168,percent of total billed charges,50% of total billed charges,134.19,31.95,,107.352,percent of total billed charges,31.95% of total billed charges,134.19,31.95,,107.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,159.6,38,,127.68,percent of total billed charges,38% of total billed charges,168,40,,134.4,percent of total billed charges,40% of total billed charges,4797.94,6449,
MENISCAL ROOT KIT,4202784,CDM,270,RC,,,OUTPATIENT,,,2985,1791,,2537.25,85,,2029.8,Percent of total billed charges,85% of total billed charges,1492.5,50,,1194,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1492.5,50,,1194,percent of total billed charges,50% of total billed charges,953.71,31.95,,762.968,percent of total billed charges,31.95% of total billed charges,953.71,31.95,,762.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1134.3,38,,907.44,percent of total billed charges,38% of total billed charges,1194,40,,955.2,percent of total billed charges,40% of total billed charges,4798.94,6450,
"PT THRDED CANN W/NO SQRT CAP, 7MMX11CM",4202785,CDM,270,RC,,,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,30,percent of total billed charges,50% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,22.8,percent of total billed charges,38% of total billed charges,30,40,,24,percent of total billed charges,40% of total billed charges,4799.94,6451,
"FW,BPB #2 SUTR, BLU W/NDL",4202786,CDM,270,RC,,,OUTPATIENT,,,66,39.6,,56.1,85,,44.88,Percent of total billed charges,85% of total billed charges,33,50,,26.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33,50,,26.4,percent of total billed charges,50% of total billed charges,21.09,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,21.09,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.08,38,,20.064,percent of total billed charges,38% of total billed charges,26.4,40,,21.12,percent of total billed charges,40% of total billed charges,4800.94,6452,
"FIBERLINK 0, BLUE",4202787,CDM,270,RC,,,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,97.5,50,,78,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,97.5,50,,78,percent of total billed charges,50% of total billed charges,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,74.1,38,,59.28,percent of total billed charges,38% of total billed charges,78,40,,62.4,percent of total billed charges,40% of total billed charges,4801.94,6453,
SERFAS ENERGY 90-S CRUISE,4202788,CDM,270,RC,,,OUTPATIENT,,,538,322.8,,457.3,85,,365.84,Percent of total billed charges,85% of total billed charges,269,50,,215.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,269,50,,215.2,percent of total billed charges,50% of total billed charges,171.89,31.95,,137.512,percent of total billed charges,31.95% of total billed charges,171.89,31.95,,137.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,204.44,38,,163.552,percent of total billed charges,38% of total billed charges,215.2,40,,172.16,percent of total billed charges,40% of total billed charges,4802.94,6454,
RF 2 PROBES 50-S,4202789,CDM,270,RC,,,OUTPATIENT,,,629,377.4,,534.65,85,,427.72,Percent of total billed charges,85% of total billed charges,314.5,50,,251.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,314.5,50,,251.6,percent of total billed charges,50% of total billed charges,200.97,31.95,,160.776,percent of total billed charges,31.95% of total billed charges,200.97,31.95,,160.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,239.02,38,,191.216,percent of total billed charges,38% of total billed charges,251.6,40,,201.28,percent of total billed charges,40% of total billed charges,4803.94,6455,
TOMCAT HC SHAVER BLADE 4.0MM,4202791,CDM,270,RC,,,OUTPATIENT,,,260,156,,221,85,,176.8,Percent of total billed charges,85% of total billed charges,130,50,,104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,130,50,,104,percent of total billed charges,50% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,98.8,38,,79.04,percent of total billed charges,38% of total billed charges,104,40,,83.2,percent of total billed charges,40% of total billed charges,4804.94,6456,
AGGRESSIVE MAX SHAVER  BLADE 3.5MM,4202792,CDM,270,RC,,,OUTPATIENT,,,260,156,,221,85,,176.8,Percent of total billed charges,85% of total billed charges,130,50,,104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,130,50,,104,percent of total billed charges,50% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,98.8,38,,79.04,percent of total billed charges,38% of total billed charges,104,40,,83.2,percent of total billed charges,40% of total billed charges,4805.94,6457,
GELPORT LAPAROSCOPIC SYSTEM,4202793,CDM,270,RC,,,OUTPATIENT,,,1197,718.2,,1017.45,85,,813.96,Percent of total billed charges,85% of total billed charges,598.5,50,,478.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,598.5,50,,478.8,percent of total billed charges,50% of total billed charges,382.44,31.95,,305.952,percent of total billed charges,31.95% of total billed charges,382.44,31.95,,305.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,454.86,38,,363.888,percent of total billed charges,38% of total billed charges,478.8,40,,383.04,percent of total billed charges,40% of total billed charges,4806.94,6458,
4.0 DUAL EDGE CUTTER,4202794,CDM,270,RC,,,OUTPATIENT,,,260,156,,221,85,,176.8,Percent of total billed charges,85% of total billed charges,130,50,,104,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,130,50,,104,percent of total billed charges,50% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,98.8,38,,79.04,percent of total billed charges,38% of total billed charges,104,40,,83.2,percent of total billed charges,40% of total billed charges,4807.94,6459,
2.4MM ROUND BUR,4202795,CDM,270,RC,,,OUTPATIENT,,,193,115.8,,164.05,85,,131.24,Percent of total billed charges,85% of total billed charges,96.5,50,,77.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.5,50,,77.2,percent of total billed charges,50% of total billed charges,61.66,31.95,,49.328,percent of total billed charges,31.95% of total billed charges,61.66,31.95,,49.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.34,38,,58.672,percent of total billed charges,38% of total billed charges,77.2,40,,61.76,percent of total billed charges,40% of total billed charges,4808.94,6460,
4.0MM ROUND FAST CUTTING BUR,4202796,CDM,270,RC,,,OUTPATIENT,,,173,103.8,,147.05,85,,117.64,Percent of total billed charges,85% of total billed charges,86.5,50,,69.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,86.5,50,,69.2,percent of total billed charges,50% of total billed charges,55.27,31.95,,44.216,percent of total billed charges,31.95% of total billed charges,55.27,31.95,,44.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,65.74,38,,52.592,percent of total billed charges,38% of total billed charges,69.2,40,,55.36,percent of total billed charges,40% of total billed charges,4809.94,6461,
4.0 AGGRESSIVE 6 FLUTE,4202797,CDM,270,RC,,,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,60.8,percent of total billed charges,38% of total billed charges,80,40,,64,percent of total billed charges,40% of total billed charges,4810.94,6462,
TENDON TIBIALIS GRAFT,4202798,CDM,270,RC,,,OUTPATIENT,,,6300,3780,,5355,85,,4284,Percent of total billed charges,85% of total billed charges,3150,50,,2520,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3150,50,,2520,percent of total billed charges,50% of total billed charges,2012.85,31.95,,1610.28,percent of total billed charges,31.95% of total billed charges,2012.85,31.95,,1610.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2394,38,,1915.2,percent of total billed charges,38% of total billed charges,2520,40,,2016,percent of total billed charges,40% of total billed charges,4811.94,6463,
D520 TUBING STOPCOCK SET DISCOFIX EXT,4202799,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4812.94,6464,
SPINAL NEEDLE 18GX3.5 QUINCKE,4202800,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,1.52,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4813.94,6465,
BLADE SAW OSCILLATING 9X31X.38MM,4202801,CDM,270,RC,,,OUTPATIENT,,,73,43.8,,62.05,85,,49.64,Percent of total billed charges,85% of total billed charges,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36.5,50,,29.2,percent of total billed charges,50% of total billed charges,23.32,31.95,,18.656,percent of total billed charges,31.95% of total billed charges,23.32,31.95,,18.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.74,38,,22.192,percent of total billed charges,38% of total billed charges,29.2,40,,23.36,percent of total billed charges,40% of total billed charges,4814.94,6466,
NEEDLE MAYO CATGUT 1/2 CIR TAPERED SZ 6,4202802,CDM,270,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4815.94,6467,
MDI IMPLANT SIZE 2,4202803,CDM,270,RC,,,OUTPATIENT,,,5700,3420,,4845,85,,3876,Percent of total billed charges,85% of total billed charges,2850,50,,2280,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2850,50,,2280,percent of total billed charges,50% of total billed charges,1821.15,31.95,,1456.92,percent of total billed charges,31.95% of total billed charges,1821.15,31.95,,1456.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2166,38,,1732.8,percent of total billed charges,38% of total billed charges,2280,40,,1824,percent of total billed charges,40% of total billed charges,4816.94,6468,
MEDIUM MICRO AGGRESSIVE SAW BLADE THIN OSCILLATING  SAGITTA,4202804,CDM,270,RC,,,OUTPATIENT,,,29,17.4,,24.65,85,,19.72,Percent of total billed charges,85% of total billed charges,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14.5,50,,11.6,percent of total billed charges,50% of total billed charges,9.27,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,9.27,31.95,,7.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.02,38,,8.816,percent of total billed charges,38% of total billed charges,11.6,40,,9.28,percent of total billed charges,40% of total billed charges,4817.94,6469,
PACK SURGICAL PROCEDURE CUSTOM SETUP ACL W/DEVICE,4202805,CDM,270,RC,,,OUTPATIENT,,,1261,756.6,,1071.85,85,,857.48,Percent of total billed charges,85% of total billed charges,630.5,50,,504.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,630.5,50,,504.4,percent of total billed charges,50% of total billed charges,402.89,31.95,,322.312,percent of total billed charges,31.95% of total billed charges,402.89,31.95,,322.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,479.18,38,,383.344,percent of total billed charges,38% of total billed charges,504.4,40,,403.52,percent of total billed charges,40% of total billed charges,4818.94,6470,
GUIDEPIN ARTHROSCOPIC VERSITOMIC NON-STERILE DISPOSABLE,4202806,CDM,270,RC,,,OUTPATIENT,,,750,450,,637.5,85,,510,Percent of total billed charges,85% of total billed charges,375,50,,300,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,375,50,,300,percent of total billed charges,50% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,300,40,,240,percent of total billed charges,40% of total billed charges,4819.94,6471,
ANCHOR SOFT TISSUE 25MM DIA LOOP PEEK NON-RESORBABLE KNOTILU,4202807,CDM,270,RC,,,OUTPATIENT,,,645,387,,548.25,85,,438.6,Percent of total billed charges,85% of total billed charges,322.5,50,,258,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,322.5,50,,258,percent of total billed charges,50% of total billed charges,206.08,31.95,,164.864,percent of total billed charges,31.95% of total billed charges,206.08,31.95,,164.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,245.1,38,,196.08,percent of total billed charges,38% of total billed charges,258,40,,206.4,percent of total billed charges,40% of total billed charges,4820.94,6472,
10MM X 23MM BIOSTEON SCREW,4202808,CDM,270,RC,,,OUTPATIENT,,,861,516.6,,731.85,85,,585.48,Percent of total billed charges,85% of total billed charges,430.5,50,,344.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,430.5,50,,344.4,percent of total billed charges,50% of total billed charges,275.09,31.95,,220.072,percent of total billed charges,31.95% of total billed charges,275.09,31.95,,220.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,327.18,38,,261.744,percent of total billed charges,38% of total billed charges,344.4,40,,275.52,percent of total billed charges,40% of total billed charges,4821.94,6473,
PROCLINCH RT REVERSE TENSIONIN,4202809,CDM,270,RC,,,OUTPATIENT,,,1350,810,,1147.5,85,,918,Percent of total billed charges,85% of total billed charges,675,50,,540,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,675,50,,540,percent of total billed charges,50% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,513,38,,410.4,percent of total billed charges,38% of total billed charges,540,40,,432,percent of total billed charges,40% of total billed charges,4822.94,6474,
SUCTION DEVICE FLOOR PUDDLEVAC,4202810,CDM,270,RC,,,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,23,50,,18.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23,50,,18.4,percent of total billed charges,50% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,13.984,percent of total billed charges,38% of total billed charges,18.4,40,,14.72,percent of total billed charges,40% of total billed charges,4823.94,6475,
BRACE SOFT SHOULDER IMMOBILIZER XL,4202811,CDM,270,RC,,,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,87.5,50,,70,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.5,50,,70,percent of total billed charges,50% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.5,38,,53.2,percent of total billed charges,38% of total billed charges,70,40,,56,percent of total billed charges,40% of total billed charges,4824.94,6476,
BRACE SOFT SHOULDER IMMOBILIZER LARGE,4202812,CDM,270,RC,,,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,87.5,50,,70,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.5,50,,70,percent of total billed charges,50% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.5,38,,53.2,percent of total billed charges,38% of total billed charges,70,40,,56,percent of total billed charges,40% of total billed charges,4825.94,6477,
BRACE SOFT SHOULDER IMMOBILIZER MEDIUM,4202813,CDM,270,RC,,,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,87.5,50,,70,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.5,50,,70,percent of total billed charges,50% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.5,38,,53.2,percent of total billed charges,38% of total billed charges,70,40,,56,percent of total billed charges,40% of total billed charges,4826.94,6478,
BRACE SOFT SHOULDER IMMOBILIZER SMALL,4202814,CDM,270,RC,,,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,87.5,50,,70,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.5,50,,70,percent of total billed charges,50% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.5,38,,53.2,percent of total billed charges,38% of total billed charges,70,40,,56,percent of total billed charges,40% of total billed charges,4827.94,6479,
SILVER DRESSING SILVERLON ISLAND 4 X 10 INCH RECTANGLE STERI,4202815,CDM,270,RC,,,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57.5,50,,46,percent of total billed charges,50% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,46,40,,36.8,percent of total billed charges,40% of total billed charges,4828.94,6480,
SILVER DRESSING SILVERLON ISLAND 4 X 6 INCH RECTANGLE STERIL,4202816,CDM,270,RC,,,OUTPATIENT,,,57,34.2,,48.45,85,,38.76,Percent of total billed charges,85% of total billed charges,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28.5,50,,22.8,percent of total billed charges,50% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,17.328,percent of total billed charges,38% of total billed charges,22.8,40,,18.24,percent of total billed charges,40% of total billed charges,4829.94,6481,
CANNULATED COMPRESSION SCREW / S.S.,4202817,CDM,270,RC,,,OUTPATIENT,,,713,427.8,,606.05,85,,484.84,Percent of total billed charges,85% of total billed charges,356.5,50,,285.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,356.5,50,,285.2,percent of total billed charges,50% of total billed charges,227.8,31.95,,182.24,percent of total billed charges,31.95% of total billed charges,227.8,31.95,,182.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,270.94,38,,216.752,percent of total billed charges,38% of total billed charges,285.2,40,,228.16,percent of total billed charges,40% of total billed charges,4830.94,6482,
COUNTERSINK,4202818,CDM,270,RC,,,OUTPATIENT,,,570,342,,484.5,85,,387.6,Percent of total billed charges,85% of total billed charges,285,50,,228,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,285,50,,228,percent of total billed charges,50% of total billed charges,182.12,31.95,,145.696,percent of total billed charges,31.95% of total billed charges,182.12,31.95,,145.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,216.6,38,,173.28,percent of total billed charges,38% of total billed charges,228,40,,182.4,percent of total billed charges,40% of total billed charges,4831.94,6483,
K-WIRE SINGLE TROCAR POINT,4202819,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,125,75,,131.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,43.94,35.15,,35.152,percent of total billed charges,35.15% of total billed charges,147.08,31.95,,117.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.5,38,,38,percent of total billed charges,38% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,4832.94,6484,
CHAMPION PASSER NEEDLE,4202821,CDM,270,RC,,,OUTPATIENT,,,582,349.2,,494.7,85,,395.76,Percent of total billed charges,85% of total billed charges,291,50,,232.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,291,50,,232.8,percent of total billed charges,50% of total billed charges,185.95,31.95,,148.76,percent of total billed charges,31.95% of total billed charges,185.95,31.95,,148.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,221.16,38,,176.928,percent of total billed charges,38% of total billed charges,232.8,40,,186.24,percent of total billed charges,40% of total billed charges,4833.94,6485,
ICONIX SPEED ANCHOR 2.3MM 2 STRAND #2 FORCE FIBER SUTURE,4202822,CDM,270,RC,,,OUTPATIENT,,,1545,927,,1313.25,85,,1050.6,Percent of total billed charges,85% of total billed charges,772.5,50,,618,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,772.5,50,,618,percent of total billed charges,50% of total billed charges,493.63,31.95,,394.904,percent of total billed charges,31.95% of total billed charges,493.63,31.95,,394.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,587.1,38,,469.68,percent of total billed charges,38% of total billed charges,618,40,,494.4,percent of total billed charges,40% of total billed charges,4834.94,6486,
ANCHOR KIT 2.5X10MM,4202823,CDM,270,RC,,,OUTPATIENT,,,1387,832.2,,1178.95,85,,943.16,Percent of total billed charges,85% of total billed charges,693.5,50,,554.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,693.5,50,,554.8,percent of total billed charges,50% of total billed charges,443.15,31.95,,354.52,percent of total billed charges,31.95% of total billed charges,443.15,31.95,,354.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,527.06,38,,421.648,percent of total billed charges,38% of total billed charges,554.8,40,,443.84,percent of total billed charges,40% of total billed charges,4835.94,6487,
DRILL D2.8,4202824,CDM,270,RC,,,OUTPATIENT,,,6250,3750,,5312.5,85,,4250,Percent of total billed charges,85% of total billed charges,3125,50,,2500,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3125,50,,2500,percent of total billed charges,50% of total billed charges,1996.88,31.95,,1597.504,percent of total billed charges,31.95% of total billed charges,1996.88,31.95,,1597.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2375,38,,1900,percent of total billed charges,38% of total billed charges,2500,40,,2000,percent of total billed charges,40% of total billed charges,4836.94,6488,
SPEEDGUIDE FOR 2.4/2.7MM T8(L=30MM),4202825,CDM,270,RC,,,OUTPATIENT,,,1010,606,,858.5,85,,686.8,Percent of total billed charges,85% of total billed charges,505,50,,404,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,505,50,,404,percent of total billed charges,50% of total billed charges,322.7,31.95,,258.16,percent of total billed charges,31.95% of total billed charges,322.7,31.95,,258.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,383.8,38,,307.04,percent of total billed charges,38% of total billed charges,404,40,,323.2,percent of total billed charges,40% of total billed charges,4837.94,6489,
"SPEEDGUIDE DRILL AO, DIA 2.0MM (L = 30MM).",4202826,CDM,270,RC,,,OUTPATIENT,,,530,318,,450.5,85,,360.4,Percent of total billed charges,85% of total billed charges,265,50,,212,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,265,50,,212,percent of total billed charges,50% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,201.4,38,,161.12,percent of total billed charges,38% of total billed charges,212,40,,169.6,percent of total billed charges,40% of total billed charges,4838.94,6490,
LOCKING PEG T8 2.0MM / L22MM,4202827,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,147.93,31.95,,118.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,4839.94,6491,
LOCKING PEG T8 2.0MM / L16MM,4202828,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,149.53,31.95,,119.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,4840.94,6492,
LOCKING PEG T8 2.0MM / L20MM,4202829,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,318,190.8,,333.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,111.78,35.15,,89.424,percent of total billed charges,35.15% of total billed charges,150.17,31.95,,120.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,120.84,38,,96.672,percent of total billed charges,38% of total billed charges,101.6,31.95,,81.28,percent of total billed charges,31.95% of total billed charges,4841.94,6493,
SECUR-FIT MAX 132 HIP STEM #8,4202830,CDM,270,RC,,,OUTPATIENT,,,3217,1930.2,,2734.45,85,,2187.56,Percent of total billed charges,85% of total billed charges,1608.5,50,,1286.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1608.5,50,,1286.8,percent of total billed charges,50% of total billed charges,1027.83,31.95,,822.264,percent of total billed charges,31.95% of total billed charges,1027.83,31.95,,822.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1222.46,38,,977.968,percent of total billed charges,38% of total billed charges,1286.8,40,,1029.44,percent of total billed charges,40% of total billed charges,4842.94,6494,
UHR BIPOLAR 26X42MM,4202831,CDM,270,RC,,,OUTPATIENT,,,1614,968.4,,1371.9,85,,1097.52,Percent of total billed charges,85% of total billed charges,807,50,,645.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,807,50,,645.6,percent of total billed charges,50% of total billed charges,515.67,31.95,,412.536,percent of total billed charges,31.95% of total billed charges,515.67,31.95,,412.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,613.32,38,,490.656,percent of total billed charges,38% of total billed charges,645.6,40,,516.48,percent of total billed charges,40% of total billed charges,4843.94,6495,
C-TAPER COCR LFIT HEAD 26MM/0,4202832,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,150.8,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,4844.94,6496,
"CANNULA 8.0MM X 75MM, THREADED",4202833,CDM,270,RC,,,OUTPATIENT,,,71,42.6,,60.35,85,,48.28,Percent of total billed charges,85% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,22.68,31.95,,18.144,percent of total billed charges,31.95% of total billed charges,22.68,31.95,,18.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.98,38,,21.584,percent of total billed charges,38% of total billed charges,28.4,40,,22.72,percent of total billed charges,40% of total billed charges,4845.94,6497,
"CANNULA 6.5MM X 75MM, THREADED",4202834,CDM,270,RC,,,OUTPATIENT,,,71,42.6,,60.35,85,,48.28,Percent of total billed charges,85% of total billed charges,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35.5,50,,28.4,percent of total billed charges,50% of total billed charges,22.68,31.95,,18.144,percent of total billed charges,31.95% of total billed charges,22.68,31.95,,18.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.98,38,,21.584,percent of total billed charges,38% of total billed charges,28.4,40,,22.72,percent of total billed charges,40% of total billed charges,4846.94,6498,
REEIX 5TT 4.5 ANCHOR,4202835,CDM,270,RC,,,OUTPATIENT,,,1312,787.2,,1115.2,85,,892.16,Percent of total billed charges,85% of total billed charges,656,50,,524.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,656,50,,524.8,percent of total billed charges,50% of total billed charges,419.18,31.95,,335.344,percent of total billed charges,31.95% of total billed charges,419.18,31.95,,335.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,498.56,38,,398.848,percent of total billed charges,38% of total billed charges,524.8,40,,419.84,percent of total billed charges,40% of total billed charges,4847.94,6499,
FORCE FIBER SIZE 2 CO BRAID SUTURE W/NEEDLE,4202836,CDM,270,RC,,,OUTPATIENT,,,49,29.4,,41.65,85,,33.32,Percent of total billed charges,85% of total billed charges,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24.5,50,,19.6,percent of total billed charges,50% of total billed charges,15.66,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,15.66,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.62,38,,14.896,percent of total billed charges,38% of total billed charges,19.6,40,,15.68,percent of total billed charges,40% of total billed charges,4848.94,6500,
TKR BOOT LINERS,4202837,CDM,270,RC,,,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57.5,50,,46,percent of total billed charges,50% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,46,40,,36.8,percent of total billed charges,40% of total billed charges,4849.94,6501,
DRESSING 4X4 COLLAGEN PURACOL PLUS AG,4202838,CDM,270,RC,,,OUTPATIENT,,,61,36.6,,51.85,85,,41.48,Percent of total billed charges,85% of total billed charges,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30.5,50,,24.4,percent of total billed charges,50% of total billed charges,19.49,31.95,,15.592,percent of total billed charges,31.95% of total billed charges,19.49,31.95,,15.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,23.18,38,,18.544,percent of total billed charges,38% of total billed charges,24.4,40,,19.52,percent of total billed charges,40% of total billed charges,4850.94,6502,
DRESSING OPTIFOAM 1.6''X2'' GENTLE  BORDER,4202839,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4851.94,6503,
DRESSING OPTIFOAM 3''X3'' GENTLE  BORDER,4202840,CDM,270,RC,,,OUTPATIENT,,,5,3,,4.25,85,,3.4,Percent of total billed charges,85% of total billed charges,2.5,50,,2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2.5,50,,2,percent of total billed charges,50% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.9,38,,1.52,percent of total billed charges,38% of total billed charges,2,40,,1.6,percent of total billed charges,40% of total billed charges,4852.94,6504,
DRESSING OPTIFOAM 6''X6'' GENTLE BORDER,4202841,CDM,270,RC,,,OUTPATIENT,,,7,4.2,,5.95,85,,4.76,Percent of total billed charges,85% of total billed charges,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3.5,50,,2.8,percent of total billed charges,50% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,2.24,31.95,,1.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.66,38,,2.128,percent of total billed charges,38% of total billed charges,2.8,40,,2.24,percent of total billed charges,40% of total billed charges,4853.94,6505,
DRESSING POLYMEM FILM DOT ADHESIVE,4202843,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4854.94,6506,
DRESSING WIC SILVER ROPE,4202844,CDM,270,RC,,,OUTPATIENT,,,38,22.8,,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,19,50,,15.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19,50,,15.2,percent of total billed charges,50% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,11.552,percent of total billed charges,38% of total billed charges,15.2,40,,12.16,percent of total billed charges,40% of total billed charges,4855.94,6507,
SUTURE 2.0 PROLENE 30IN BLUE KS SC-2 SC1 KS/SC-2/CS-1/GS60 7,4202845,CDM,270,RC,,,OUTPATIENT,,,8,4.8,,6.8,85,,5.44,Percent of total billed charges,85% of total billed charges,4,50,,3.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4,50,,3.2,percent of total billed charges,50% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.04,38,,2.432,percent of total billed charges,38% of total billed charges,3.2,40,,2.56,percent of total billed charges,40% of total billed charges,4856.94,6508,
"STERILE MODIFIED HALL MODULAR SHAFT, 450MM",4202846,CDM,272,RC,,,OUTPATIENT,,,795,477,,675.75,85,,540.6,Percent of total billed charges,85% of total billed charges,397.5,50,,318,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,397.5,50,,318,percent of total billed charges,50% of total billed charges,254,31.95,,203.2,percent of total billed charges,31.95% of total billed charges,254,31.95,,203.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.1,38,,241.68,percent of total billed charges,38% of total billed charges,318,40,,254.4,percent of total billed charges,40% of total billed charges,4857.94,6509,
"GUIDE WIRE, BALL TIP 3X1000 STERILE",4202847,CDM,272,RC,,,OUTPATIENT,,,525,315,,446.25,85,,357,Percent of total billed charges,85% of total billed charges,262.5,50,,210,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,262.5,50,,210,percent of total billed charges,50% of total billed charges,167.74,31.95,,134.192,percent of total billed charges,31.95% of total billed charges,167.74,31.95,,134.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,199.5,38,,159.6,percent of total billed charges,38% of total billed charges,210,40,,168,percent of total billed charges,40% of total billed charges,4858.94,6510,
EVICEL FIBRIN SEALANT (HUMAN),4202848,CDM,270,RC,,,OUTPATIENT,,,2294,1376.4,,1949.9,85,,1559.92,Percent of total billed charges,85% of total billed charges,1147,50,,917.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1147,50,,917.6,percent of total billed charges,50% of total billed charges,732.93,31.95,,586.344,percent of total billed charges,31.95% of total billed charges,732.93,31.95,,586.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,871.72,38,,697.376,percent of total billed charges,38% of total billed charges,917.6,40,,734.08,percent of total billed charges,40% of total billed charges,4859.94,6511,
REVOLUTION CMS W/FEMORAL BREAKAWAY NOZZLE  MED. PRESS.,4202849,CDM,270,RC,,,OUTPATIENT,,,344,206.4,,292.4,85,,233.92,Percent of total billed charges,85% of total billed charges,172,50,,137.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,172,50,,137.6,percent of total billed charges,50% of total billed charges,109.91,31.95,,87.928,percent of total billed charges,31.95% of total billed charges,109.91,31.95,,87.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,130.72,38,,104.576,percent of total billed charges,38% of total billed charges,137.6,40,,110.08,percent of total billed charges,40% of total billed charges,4860.94,6512,
MIXEVAC III,4202850,CDM,270,RC,,,OUTPATIENT,,,142,85.2,,120.7,85,,96.56,Percent of total billed charges,85% of total billed charges,71,50,,56.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,71,50,,56.8,percent of total billed charges,50% of total billed charges,45.37,31.95,,36.296,percent of total billed charges,31.95% of total billed charges,45.37,31.95,,36.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.96,38,,43.168,percent of total billed charges,38% of total billed charges,56.8,40,,45.44,percent of total billed charges,40% of total billed charges,4861.94,6513,
"FLYTE SURGICOOL HOOD, PEELAWAY",4202852,CDM,270,RC,,,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,52.5,50,,42,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.5,50,,42,percent of total billed charges,50% of total billed charges,33.55,31.95,,26.84,percent of total billed charges,31.95% of total billed charges,33.55,31.95,,26.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.9,38,,31.92,percent of total billed charges,38% of total billed charges,42,40,,33.6,percent of total billed charges,40% of total billed charges,4862.94,6514,
ABDUCTION PILLOW LARGE,4202855,CDM,270,RC,,,OUTPATIENT,,,104,62.4,,88.4,85,,70.72,Percent of total billed charges,85% of total billed charges,52,50,,41.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52,50,,41.6,percent of total billed charges,50% of total billed charges,33.23,31.95,,26.584,percent of total billed charges,31.95% of total billed charges,33.23,31.95,,26.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.52,38,,31.616,percent of total billed charges,38% of total billed charges,41.6,40,,33.28,percent of total billed charges,40% of total billed charges,4863.94,6515,
SUTURE 5.0 SILK 18IN BLACK PS-2 P-12,4202856,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,2.736,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4864.94,6516,
PULMODYME MASK SMALL,4202857,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4865.94,6517,
PULMODYME MASK LARGE,4202859,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4866.94,6518,
DRESSING COLLAGEN PURACOL PLUS 2X2,4202860,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,6.4,40,,5.12,percent of total billed charges,40% of total billed charges,4867.94,6519,
SINGLE-UNIT DEVICE INCLUDING 1 PLUG 40,4202861,CDM,270,RC,,,OUTPATIENT,,,754,452.4,,640.9,85,,512.72,Percent of total billed charges,85% of total billed charges,377,50,,301.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,377,50,,301.6,percent of total billed charges,50% of total billed charges,240.9,31.95,,192.72,percent of total billed charges,31.95% of total billed charges,240.9,31.95,,192.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,286.52,38,,229.216,percent of total billed charges,38% of total billed charges,301.6,40,,241.28,percent of total billed charges,40% of total billed charges,4868.94,6520,
SINGLE-UNIT DEVICE INCLUDING 1 PLUG 55,4202862,CDM,270,RC,,,OUTPATIENT,,,754,452.4,,640.9,85,,512.72,Percent of total billed charges,85% of total billed charges,377,50,,301.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,377,50,,301.6,percent of total billed charges,50% of total billed charges,240.9,31.95,,192.72,percent of total billed charges,31.95% of total billed charges,240.9,31.95,,192.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,286.52,38,,229.216,percent of total billed charges,38% of total billed charges,301.6,40,,241.28,percent of total billed charges,40% of total billed charges,4869.94,6521,
DRAIN MALECOT 4-WING 18FR LATEX,4202864,CDM,272,RC,,,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,14.4,percent of total billed charges,50% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,11.52,percent of total billed charges,40% of total billed charges,4870.94,6522,
SURG-O-FLEX 7,4202865,CDM,270,RC,,,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.5,50,,3.6,percent of total billed charges,50% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.42,38,,2.736,percent of total billed charges,38% of total billed charges,3.6,40,,2.88,percent of total billed charges,40% of total billed charges,4871.94,6523,
"RECIPROCATING BLADE, DOUBLE SIDED, OFFSET 70.0 X 1.0 12.5MM",4202866,CDM,272,RC,,,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,67,50,,53.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67,50,,53.6,percent of total billed charges,50% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.92,38,,40.736,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,4872.94,6524,
SAGITTAL BLADE,4202867,CDM,272,RC,,,OUTPATIENT,,,192,115.2,,163.2,85,,130.56,Percent of total billed charges,85% of total billed charges,96,50,,76.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96,50,,76.8,percent of total billed charges,50% of total billed charges,61.34,31.95,,49.072,percent of total billed charges,31.95% of total billed charges,61.34,31.95,,49.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,72.96,38,,58.368,percent of total billed charges,38% of total billed charges,76.8,40,,61.44,percent of total billed charges,40% of total billed charges,4873.94,6525,
STAPLER ENDOSCOPIC (POWER) ARTICULATING 60MM,4202868,CDM,270,RC,,,OUTPATIENT,,,1124,674.4,,955.4,85,,764.32,Percent of total billed charges,85% of total billed charges,562,50,,449.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,562,50,,449.6,percent of total billed charges,50% of total billed charges,359.12,31.95,,287.296,percent of total billed charges,31.95% of total billed charges,359.12,31.95,,287.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,427.12,38,,341.696,percent of total billed charges,38% of total billed charges,449.6,40,,359.68,percent of total billed charges,40% of total billed charges,4874.94,6526,
ULTRATOUCH SZ 6 1/2 BIOGEL SURGICAL GLOVE,4202869,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4875.94,6527,
SUTURE 1.0 VICYRL OS-4 UNDYED,4202873,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4876.94,6528,
COLOSTOMY POWDER 1 OZ,4202874,CDM,270,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,5.168,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4877.94,6529,
AQUACEL AG SURGICAL W/SILVER 3.5'' X 14'',4202875,CDM,270,RC,,,OUTPATIENT,,,111,66.6,,94.35,85,,75.48,Percent of total billed charges,85% of total billed charges,55.5,50,,44.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,55.5,50,,44.4,percent of total billed charges,50% of total billed charges,35.46,31.95,,28.368,percent of total billed charges,31.95% of total billed charges,35.46,31.95,,28.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.18,38,,33.744,percent of total billed charges,38% of total billed charges,44.4,40,,35.52,percent of total billed charges,40% of total billed charges,4878.94,6530,
DR. BURTON VPEP DEVICE FOR OPEP THERAPY,4202880,CDM,270,RC,,,OUTPATIENT,,,87,52.2,,73.95,85,,59.16,Percent of total billed charges,85% of total billed charges,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,43.5,50,,34.8,percent of total billed charges,50% of total billed charges,27.8,31.95,,22.24,percent of total billed charges,31.95% of total billed charges,27.8,31.95,,22.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.06,38,,26.448,percent of total billed charges,38% of total billed charges,34.8,40,,27.84,percent of total billed charges,40% of total billed charges,4879.94,6531,
BANDAGING SYSTEM THREE LAYER PROFORE,4202881,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,6.384,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4880.94,6532,
FLAT PROXIMAL PRESSURIZER,4202882,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,13.376,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4881.94,6533,
"FEMORAL CANAL PRESSURIZER WITHOUT HUB, SMALL, YELLOW",4202883,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,13.376,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4882.94,6534,
"FEMORAL CANAL PRESSURIZER WITHOUT HUB, MEDIUM, BLUE",4202884,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,13.376,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4883.94,6535,
"FEMORAL CANAL PRESSURIZER WITHOUT HUB, LARGE RED",4202885,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,13.376,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4884.94,6536,
REVOLUTION HUMERAL NOZZLE,4202886,CDM,270,RC,,,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.14,38,,16.112,percent of total billed charges,38% of total billed charges,21.2,40,,16.96,percent of total billed charges,40% of total billed charges,4885.94,6537,
NOZIN NASAL SANITIZER AMPULE,4202887,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4886.94,6538,
ethyl alcohol nasal 62% swab [FMC],4202887,CDM,636,RC,,,OUTPATIENT,,,21.09,12.654,,17.93,85,,14.344,Percent of total billed charges,85% of total billed charges,10.55,50,,8.44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.55,50,,8.44,percent of total billed charges,50% of total billed charges,6.74,31.95,,5.392,percent of total billed charges,31.95% of total billed charges,6.74,31.95,,5.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8.44,40,,6.752,percent of total billed charges,40% of total billed charges,4887.94,6539,
SKIN STAPLER PROXIMATE ROTATING HEAD WIDE COUNT X 35 DISPOSA,4202888,CDM,270,RC,,,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.14,38,,16.112,percent of total billed charges,38% of total billed charges,21.2,40,,16.96,percent of total billed charges,40% of total billed charges,4888.94,6540,
CARPAL TUNNEL PROTECTOR LEFT HAND,4202889,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,4889.94,6541,
CROSSFLOW OUTFLOW CASSETTE TUBING,4202891,CDM,270,RC,,,OUTPATIENT,,,173,103.8,,147.05,85,,117.64,Percent of total billed charges,85% of total billed charges,86.5,50,,69.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,86.5,50,,69.2,percent of total billed charges,50% of total billed charges,55.27,31.95,,44.216,percent of total billed charges,31.95% of total billed charges,55.27,31.95,,44.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,65.74,38,,52.592,percent of total billed charges,38% of total billed charges,69.2,40,,55.36,percent of total billed charges,40% of total billed charges,4890.94,6542,
INTRANASAL ADOMIZER,4202893,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4891.94,6543,
MEDIHONEY WOUND GEL 5 OZ.,4202894,CDM,270,RC,,,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.98,38,,6.384,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,4892.94,6544,
"TUBE, SUCTION, FRAZIER, CTRL VENT, STRL, 18FR",4202895,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4893.94,6545,
"TYMPANIC TEMP PROBE, ADULT",4202896,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4894.94,6546,
FMT LOWER DELIVERY,4202898,CDM,279,RC,,,OUTPATIENT,,,1945,1167,,1653.25,85,,1322.6,Percent of total billed charges,85% of total billed charges,972.5,50,,778,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,972.5,50,,778,percent of total billed charges,50% of total billed charges,621.43,31.95,,497.144,percent of total billed charges,31.95% of total billed charges,621.43,31.95,,497.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,739.1,38,,591.28,percent of total billed charges,38% of total billed charges,778,40,,622.4,percent of total billed charges,40% of total billed charges,4895.94,6547,
FMT UPPER DELIVERY,4202899,CDM,279,RC,,,OUTPATIENT,,,1945,1167,,1653.25,85,,1322.6,Percent of total billed charges,85% of total billed charges,972.5,50,,778,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,972.5,50,,778,percent of total billed charges,50% of total billed charges,621.43,31.95,,497.144,percent of total billed charges,31.95% of total billed charges,621.43,31.95,,497.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,739.1,38,,591.28,percent of total billed charges,38% of total billed charges,778,40,,622.4,percent of total billed charges,40% of total billed charges,4896.94,6548,
FMT CAPSULE DE,4202900,CDM,279,RC,,,OUTPATIENT,,,2300,1380,,1955,85,,1564,Percent of total billed charges,85% of total billed charges,1150,50,,920,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1150,50,,920,percent of total billed charges,50% of total billed charges,734.85,31.95,,587.88,percent of total billed charges,31.95% of total billed charges,734.85,31.95,,587.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,874,38,,699.2,percent of total billed charges,38% of total billed charges,920,40,,736,percent of total billed charges,40% of total billed charges,4897.94,6549,
SURGIDAC LOADING UNIT ENDO STITCH GREEN 2.0 48IN,4202901,CDM,270,RC,,,OUTPATIENT,,,185,111,,157.25,85,,125.8,Percent of total billed charges,85% of total billed charges,92.5,50,,74,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,92.5,50,,74,percent of total billed charges,50% of total billed charges,59.11,31.95,,47.288,percent of total billed charges,31.95% of total billed charges,59.11,31.95,,47.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.3,38,,56.24,percent of total billed charges,38% of total billed charges,74,40,,59.2,percent of total billed charges,40% of total billed charges,4898.94,6550,
FLAT SHEET 7 X 10 CM PATCH,4202902,CDM,270,RC,,,OUTPATIENT,,,1000,600,,850,85,,680,Percent of total billed charges,85% of total billed charges,500,50,,400,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,500,50,,400,percent of total billed charges,50% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,304,percent of total billed charges,38% of total billed charges,400,40,,320,percent of total billed charges,40% of total billed charges,4899.94,6551,
SUTURE 1.0 PROLENE CT-1 18'',4202903,CDM,270,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,4900.94,6552,
MULTIDEBRIDER TUBESET DECLOG,4202904,CDM,272,RC,,,OUTPATIENT,,,127,76.2,,107.95,85,,86.36,Percent of total billed charges,85% of total billed charges,63.5,50,,50.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,63.5,50,,50.8,percent of total billed charges,50% of total billed charges,40.58,31.95,,32.464,percent of total billed charges,31.95% of total billed charges,40.58,31.95,,32.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,48.26,38,,38.608,percent of total billed charges,38% of total billed charges,50.8,40,,40.64,percent of total billed charges,40% of total billed charges,4901.94,6553,
DIEGO ELETE BLADE NOSECONE ADAPTERE GRIP,4202905,CDM,272,RC,,,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,6,50,,4.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6,50,,4.8,percent of total billed charges,50% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,4.8,40,,3.84,percent of total billed charges,40% of total billed charges,4902.94,6554,
SUCTION MODULE TUBE SET,4202906,CDM,272,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,4903.94,6555,
BIPOLAR BLADE 2MM SMR TYPE A,4202907,CDM,272,RC,,,OUTPATIENT,,,490,294,,416.5,85,,333.2,Percent of total billed charges,85% of total billed charges,245,50,,196,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,245,50,,196,percent of total billed charges,50% of total billed charges,156.56,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,156.56,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,186.2,38,,148.96,percent of total billed charges,38% of total billed charges,196,40,,156.8,percent of total billed charges,40% of total billed charges,4904.94,6556,
"BIOPOLAR BLADE 4MM 40DEG CONVEX, SERR",4202908,CDM,272,RC,,,OUTPATIENT,,,530,318,,450.5,85,,360.4,Percent of total billed charges,85% of total billed charges,265,50,,212,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,265,50,,212,percent of total billed charges,50% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,201.4,38,,161.12,percent of total billed charges,38% of total billed charges,212,40,,169.6,percent of total billed charges,40% of total billed charges,4905.94,6557,
"MALLEABLE, MONOPOLAR T/A",4202909,CDM,272,RC,,,OUTPATIENT,,,540,324,,459,85,,367.2,Percent of total billed charges,85% of total billed charges,270,50,,216,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,270,50,,216,percent of total billed charges,50% of total billed charges,172.53,31.95,,138.024,percent of total billed charges,31.95% of total billed charges,172.53,31.95,,138.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,205.2,38,,164.16,percent of total billed charges,38% of total billed charges,216,40,,172.8,percent of total billed charges,40% of total billed charges,4906.94,6558,
WOUNDCLOT HEMOSTAGTIC GUAZE 4X4,4202910,CDM,270,RC,,,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,4907.94,6559,
SUTURE 4.0 SOFSILK SH V-20,4202911,CDM,270,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,6.4,40,,5.12,percent of total billed charges,40% of total billed charges,4908.94,6560,
VESSEL LOOP YELLOW,4202912,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4909.94,6561,
RADIAL LINE CATHETER KIT 20G 5IN SPRING-WIRE,4202913,CDM,270,RC,,,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,32.5,50,,26,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,32.5,50,,26,percent of total billed charges,50% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,26,40,,20.8,percent of total billed charges,40% of total billed charges,4910.94,6562,
AEROSTAT 3 - 20F,4202914,CDM,270,RC,,,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,60.8,percent of total billed charges,38% of total billed charges,80,40,,64,percent of total billed charges,40% of total billed charges,4911.94,6563,
UROMAX BALLOON KIT 15F X 4CM,4202916,CDM,270,RC,,,OUTPATIENT,,,520,312,,442,85,,353.6,Percent of total billed charges,85% of total billed charges,260,50,,208,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,260,50,,208,percent of total billed charges,50% of total billed charges,166.14,31.95,,132.912,percent of total billed charges,31.95% of total billed charges,166.14,31.95,,132.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,197.6,38,,158.08,percent of total billed charges,38% of total billed charges,208,40,,166.4,percent of total billed charges,40% of total billed charges,4912.94,6564,
TIES 2.0 VICRYL 12X18'',4202917,CDM,270,RC,,,OUTPATIENT,,,22,13.2,,18.7,85,,14.96,Percent of total billed charges,85% of total billed charges,11,50,,8.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11,50,,8.8,percent of total billed charges,50% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.36,38,,6.688,percent of total billed charges,38% of total billed charges,8.8,40,,7.04,percent of total billed charges,40% of total billed charges,4913.94,6565,
COMBITUBE TUBE ADULT 37FR,4202918,CDM,270,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,4914.94,6566,
UNDERWEAR LARGE DISPOSABLE PROTECTIVE,4202919,CDM,270,RC,,,OUTPATIENT,,,14,8.4,,11.9,85,,9.52,Percent of total billed charges,85% of total billed charges,7,50,,5.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7,50,,5.6,percent of total billed charges,50% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.32,38,,4.256,percent of total billed charges,38% of total billed charges,5.6,40,,4.48,percent of total billed charges,40% of total billed charges,4915.94,6567,
Hydrofera Blue Classic Antibacterial Foam Dressing 9 mm Diam,4202920,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,9.728,percent of total billed charges,38% of total billed charges,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,4916.94,6568,
UNDERWEAR XX-LARGE DISPOSABLE PROTECTIVE,4202921,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,5.776,percent of total billed charges,38% of total billed charges,7.6,40,,6.08,percent of total billed charges,40% of total billed charges,4917.94,6569,
UNDERWEAR X-LARGE DISPOSABLE PROTECTIVE,4202922,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,5.472,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4918.94,6570,
"ANTIMICROBIAL KERLIX GUAZE ROLL, STERILE 4.5 IN  X 4.125 YDS",4202923,CDM,270,RC,,,OUTPATIENT,,,4,2.4,,3.4,85,,2.72,Percent of total billed charges,85% of total billed charges,2,50,,1.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2,50,,1.6,percent of total billed charges,50% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.52,38,,1.216,percent of total billed charges,38% of total billed charges,1.6,40,,1.28,percent of total billed charges,40% of total billed charges,4919.94,6571,
GLIDESCOPE SYTLET DISPOSABLE,4202924,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4920.94,6572,
HANDLE LARYNGOSCOPE DISPOSABLE LED,4202927,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,5.472,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4921.94,6573,
BLADE LARYNGOSCOPE DISPOSABLE MILLER 2 LED,4202928,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,5.472,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4922.94,6574,
DRESSING PINC TAPE ZINC OXIDE FIXATION TAPE 2 X 5YDS,4202931,CDM,270,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,12.16,percent of total billed charges,38% of total billed charges,16,40,,12.8,percent of total billed charges,40% of total billed charges,4923.94,6575,
MARATHON SKIN PROTECTANT LIQUID,4202932,CDM,270,RC,,,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.5,38,,7.6,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,4924.94,6576,
ZOLL PEDIATRIC DEFIBRILLATOR PAD SET,4202934,CDM,270,RC,,,OUTPATIENT,,,113,67.8,,96.05,85,,76.84,Percent of total billed charges,85% of total billed charges,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,56.5,50,,45.2,percent of total billed charges,50% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,36.1,31.95,,28.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,42.94,38,,34.352,percent of total billed charges,38% of total billed charges,45.2,40,,36.16,percent of total billed charges,40% of total billed charges,4925.94,6577,
Aspira Pleural 1000ml Drainage Bag,4202935,CDM,272,RC,,,OUTPATIENT,,,278,166.8,,236.3,85,,189.04,Percent of total billed charges,85% of total billed charges,139,50,,111.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,139,50,,111.2,percent of total billed charges,50% of total billed charges,88.82,31.95,,71.056,percent of total billed charges,31.95% of total billed charges,88.82,31.95,,71.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,105.64,38,,84.512,percent of total billed charges,38% of total billed charges,111.2,40,,88.96,percent of total billed charges,40% of total billed charges,4926.94,6578,
ZOLL DEFIB. ORAL NASAL W/CO2 CANNULA,4202936,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4927.94,6579,
UPPER DISPOSABLE INJECTOR NEEDLE 25G X 6MM,4202937,CDM,270,RC,,,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,85,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.6,38,,51.68,percent of total billed charges,38% of total billed charges,68,40,,54.4,percent of total billed charges,40% of total billed charges,4928.94,6580,
COFLEX TLC LITE 2-LAYER COMPRESSION SYSTEM,4202939,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,13.376,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4929.94,6581,
SPACE PUMP FILTERED PRIMARY IV SET,4202940,CDM,272,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,12.16,percent of total billed charges,38% of total billed charges,16,40,,12.8,percent of total billed charges,40% of total billed charges,4930.94,6582,
DRESSING MEDIGRIP SIZE D LF ELASTIC TUBULAR SUPPORT BANDAGE,4202941,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4931.94,6583,
DRESSING MEDIGRIP SIZE F LF ELASTIC TUBULAR SUPPORT BANDAGE,4202942,CDM,270,RC,,,OUTPATIENT,,,13,7.8,,11.05,85,,8.84,Percent of total billed charges,85% of total billed charges,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.5,50,,5.2,percent of total billed charges,50% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,3.952,percent of total billed charges,38% of total billed charges,5.2,40,,4.16,percent of total billed charges,40% of total billed charges,4932.94,6584,
L-HOOK WIRE 33 CM NON-COATED OLYMPUS,4202944,CDM,270,RC,,,OUTPATIENT,,,99,59.4,,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,49.5,50,,39.6,percent of total billed charges,50% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,37.62,38,,30.096,percent of total billed charges,38% of total billed charges,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,4933.94,6585,
FISTUAL NEEDLE 16G X W-CLAMP JMS A V,4202946,CDM,272,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4934.94,6586,
SUTURE PDS II ABSORBABLE MONOFILAMENT REVERSE CUTTING 1/2 CI,4202947,CDM,272,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4935.94,6587,
"SUTURE 2-0 MONOFILAMENT NYLON NON-ABSORBABLE 30IN, 36MM",4202948,CDM,272,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4936.94,6588,
SUTURE 4.0 NYLON P3 18IN REVERSE CUTTING 3/8 CIRCLE,4202949,CDM,272,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,5.168,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,4937.94,6589,
CLAMP UMBILICAL,4202950,CDM,272,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,5.472,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4938.94,6590,
HAMILTON CIRCUIT AND FLOW SENSOR COMBINED,4202953,CDM,270,RC,,,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,52.5,50,,42,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,52.5,50,,42,percent of total billed charges,50% of total billed charges,33.55,31.95,,26.84,percent of total billed charges,31.95% of total billed charges,33.55,31.95,,26.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,39.9,38,,31.92,percent of total billed charges,38% of total billed charges,42,40,,33.6,percent of total billed charges,40% of total billed charges,4939.94,6591,
HAMILTON EXHALATION VALVE,4202954,CDM,270,RC,,,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,4940.94,6592,
BLADE LARYNGOSCOPE MAC 3 DISPOSABLE LED,4202955,CDM,270,RC,,,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,12,50,,9.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12,50,,9.6,percent of total billed charges,50% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.12,38,,7.296,percent of total billed charges,38% of total billed charges,9.6,40,,7.68,percent of total billed charges,40% of total billed charges,4941.94,6593,
OPTIFLUX 160,4202956,CDM,270,RC,,,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75,50,,60,percent of total billed charges,50% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,60,40,,48,percent of total billed charges,40% of total billed charges,4942.94,6594,
AEROSOL DPC HIGH VAPOTHERM,4202957,CDM,270,RC,,,OUTPATIENT,,,390,234,,331.5,85,,265.2,Percent of total billed charges,85% of total billed charges,195,50,,156,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,195,50,,156,percent of total billed charges,50% of total billed charges,124.61,31.95,,99.688,percent of total billed charges,31.95% of total billed charges,124.61,31.95,,99.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,148.2,38,,118.56,percent of total billed charges,38% of total billed charges,156,40,,124.8,percent of total billed charges,40% of total billed charges,4943.94,6595,
PED-AD SMALL HI VNI NASAL CANNULA VAPOTHERM,4202960,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4944.94,6596,
STERILE WATER 1000ML FOR INHALATION,4202961,CDM,272,RC,,,OUTPATIENT,,,140,84,,119,85,,95.2,Percent of total billed charges,85% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,70,50,,56,percent of total billed charges,50% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,56,40,,44.8,percent of total billed charges,40% of total billed charges,4945.94,6597,
THERAHONEY 1.5 OZ TUBE,4202962,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,4946.94,6598,
THERAHONEY WOUND  BURN DRESSING 2X2,4202963,CDM,270,RC,,,OUTPATIENT,,,18,10.8,,15.3,85,,12.24,Percent of total billed charges,85% of total billed charges,9,50,,7.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9,50,,7.2,percent of total billed charges,50% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.84,38,,5.472,percent of total billed charges,38% of total billed charges,7.2,40,,5.76,percent of total billed charges,40% of total billed charges,4947.94,6599,
NOZIN BOTTLE NASAL SANITIZER,4202965,CDM,270,RC,,,OUTPATIENT,,,69,41.4,,58.65,85,,46.92,Percent of total billed charges,85% of total billed charges,34.5,50,,27.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,34.5,50,,27.6,percent of total billed charges,50% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.22,38,,20.976,percent of total billed charges,38% of total billed charges,27.6,40,,22.08,percent of total billed charges,40% of total billed charges,4948.94,6600,
UNDERWEAR SMALL/MEDIUM,4202966,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4949.94,6601,
12MM SURGIGRAFT-DRY GRAFT DISC,4202967,CDM,270,RC,,,OUTPATIENT,,,220,132,,187,85,,149.6,Percent of total billed charges,85% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,110,50,,88,percent of total billed charges,50% of total billed charges,70.29,31.95,,56.232,percent of total billed charges,31.95% of total billed charges,70.29,31.95,,56.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,83.6,38,,66.88,percent of total billed charges,38% of total billed charges,88,40,,70.4,percent of total billed charges,40% of total billed charges,4950.94,6602,
15MM SURGIGRAFT-DRY GRAFT DISC,4202968,CDM,270,RC,,,OUTPATIENT,,,344,206.4,,292.4,85,,233.92,Percent of total billed charges,85% of total billed charges,172,50,,137.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,172,50,,137.6,percent of total billed charges,50% of total billed charges,109.91,31.95,,87.928,percent of total billed charges,31.95% of total billed charges,109.91,31.95,,87.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,130.72,38,,104.576,percent of total billed charges,38% of total billed charges,137.6,40,,110.08,percent of total billed charges,40% of total billed charges,4951.94,6603,
18MM SURGIGRAFT-DRY GRAFT DISC,4202969,CDM,270,RC,,,OUTPATIENT,,,360,216,,306,85,,244.8,Percent of total billed charges,85% of total billed charges,180,50,,144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,180,50,,144,percent of total billed charges,50% of total billed charges,115.02,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,115.02,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,136.8,38,,109.44,percent of total billed charges,38% of total billed charges,144,40,,115.2,percent of total billed charges,40% of total billed charges,4952.94,6604,
202 SURGIGRAFT-DRY GRAFT 2CM X 2CM,4202970,CDM,270,RC,,,OUTPATIENT,,,568,340.8,,482.8,85,,386.24,Percent of total billed charges,85% of total billed charges,284,50,,227.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,284,50,,227.2,percent of total billed charges,50% of total billed charges,181.48,31.95,,145.184,percent of total billed charges,31.95% of total billed charges,181.48,31.95,,145.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,215.84,38,,172.672,percent of total billed charges,38% of total billed charges,227.2,40,,181.76,percent of total billed charges,40% of total billed charges,4953.94,6605,
203 SURGIGRAFT-DRY GRAFT 2CM X 3CM,4202971,CDM,270,RC,,,OUTPATIENT,,,852,511.2,,724.2,85,,579.36,Percent of total billed charges,85% of total billed charges,426,50,,340.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,426,50,,340.8,percent of total billed charges,50% of total billed charges,272.21,31.95,,217.768,percent of total billed charges,31.95% of total billed charges,272.21,31.95,,217.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,323.76,38,,259.008,percent of total billed charges,38% of total billed charges,340.8,40,,272.64,percent of total billed charges,40% of total billed charges,4954.94,6606,
204 SURGIGRAFT-DRY GRAFT 2CM X 4CM,4202972,CDM,270,RC,,,OUTPATIENT,,,1136,681.6,,965.6,85,,772.48,Percent of total billed charges,85% of total billed charges,568,50,,454.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,568,50,,454.4,percent of total billed charges,50% of total billed charges,362.95,31.95,,290.36,percent of total billed charges,31.95% of total billed charges,362.95,31.95,,290.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,431.68,38,,345.344,percent of total billed charges,38% of total billed charges,454.4,40,,363.52,percent of total billed charges,40% of total billed charges,4955.94,6607,
208 SURGIGRAFT-DRY GRAFT 2CM X 8CM,4202973,CDM,270,RC,,,OUTPATIENT,,,1704,1022.4,,1448.4,85,,1158.72,Percent of total billed charges,85% of total billed charges,852,50,,681.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,852,50,,681.6,percent of total billed charges,50% of total billed charges,544.43,31.95,,435.544,percent of total billed charges,31.95% of total billed charges,544.43,31.95,,435.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,647.52,38,,518.016,percent of total billed charges,38% of total billed charges,681.6,40,,545.28,percent of total billed charges,40% of total billed charges,4956.94,6608,
404 SURGIGRAFT-DRY GRAFT 4CM X 4CM,4202974,CDM,270,RC,,,OUTPATIENT,,,1704,1022.4,,1448.4,85,,1158.72,Percent of total billed charges,85% of total billed charges,852,50,,681.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,852,50,,681.6,percent of total billed charges,50% of total billed charges,544.43,31.95,,435.544,percent of total billed charges,31.95% of total billed charges,544.43,31.95,,435.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,647.52,38,,518.016,percent of total billed charges,38% of total billed charges,681.6,40,,545.28,percent of total billed charges,40% of total billed charges,4957.94,6609,
SURGIGRAFT NANO MICROGRAFT 12.5MG/0.5CC,4202975,CDM,270,RC,,,OUTPATIENT,,,430,258,,365.5,85,,292.4,Percent of total billed charges,85% of total billed charges,215,50,,172,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,215,50,,172,percent of total billed charges,50% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.4,38,,130.72,percent of total billed charges,38% of total billed charges,172,40,,137.6,percent of total billed charges,40% of total billed charges,4958.94,6610,
BOOT FULL COVERAGE ULTRA HI GUARD,4202976,CDM,270,RC,,,OUTPATIENT,,,37,22.2,,31.45,85,,25.16,Percent of total billed charges,85% of total billed charges,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18.5,50,,14.8,percent of total billed charges,50% of total billed charges,11.82,31.95,,9.456,percent of total billed charges,31.95% of total billed charges,11.82,31.95,,9.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.06,38,,11.248,percent of total billed charges,38% of total billed charges,14.8,40,,11.84,percent of total billed charges,40% of total billed charges,4959.94,6611,
0.2 MICRON FILTER EXTENTION SET 17,4202977,CDM,270,RC,,,OUTPATIENT,,,28,16.8,,23.8,85,,19.04,Percent of total billed charges,85% of total billed charges,14,50,,11.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,14,50,,11.2,percent of total billed charges,50% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,8.95,31.95,,7.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.64,38,,8.512,percent of total billed charges,38% of total billed charges,11.2,40,,8.96,percent of total billed charges,40% of total billed charges,4960.94,6612,
CONNECTOR 6-IN-1 STERILE,4202978,CDM,272,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4961.94,6613,
MAHURKAR 12 Fr High Pressure Triple Lumen Acute Dialysis Ca,4202979,CDM,270,RC,,,OUTPATIENT,,,290,174,,246.5,85,,197.2,Percent of total billed charges,85% of total billed charges,145,50,,116,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,145,50,,116,percent of total billed charges,50% of total billed charges,92.66,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,92.66,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.2,38,,88.16,percent of total billed charges,38% of total billed charges,116,40,,92.8,percent of total billed charges,40% of total billed charges,4962.94,6614,
VSI MICRO-INTRODUCER KIT 4FR (DIALYSIS),4202980,CDM,270,RC,,,OUTPATIENT,,,138,82.8,,117.3,85,,93.84,Percent of total billed charges,85% of total billed charges,69,50,,55.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,69,50,,55.2,percent of total billed charges,50% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,52.44,38,,41.952,percent of total billed charges,38% of total billed charges,55.2,40,,44.16,percent of total billed charges,40% of total billed charges,4963.94,6615,
COVID-19 TEST KIT,4202981,CDM,270,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,10.64,percent of total billed charges,38% of total billed charges,14,40,,11.2,percent of total billed charges,40% of total billed charges,4964.94,6616,
STRYKER SAGE CHLORHEXIDINE CLOTH WIPE,4202982,CDM,270,RC,,,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,10.4,percent of total billed charges,50% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,7.904,percent of total billed charges,38% of total billed charges,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,4965.94,6617,
Stimuplex Ultra360 20GAX4IN Insulated Echogenic Needle,4202983,CDM,270,RC,,,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25.5,50,,20.4,percent of total billed charges,50% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19.38,38,,15.504,percent of total billed charges,38% of total billed charges,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,4966.94,6618,
CATHETER URINARY CONNECTOR TUBING 45.7CM,4202984,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4967.94,6619,
DIAPER ADULT SMALL,4202985,CDM,270,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,4968.94,6620,
1K ACID CONCENTRATE 4GAL,4202986,CDM,270,RC,,,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,15.6,40,,12.48,percent of total billed charges,40% of total billed charges,4969.94,6621,
2K ACID CONCENTRATE 4 GAL,4202987,CDM,270,RC,,,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,15.6,40,,12.48,percent of total billed charges,40% of total billed charges,4970.94,6622,
3K ACID CONCENTRATE 4GAL,4202988,CDM,270,RC,,,OUTPATIENT,,,39,23.4,,33.15,85,,26.52,Percent of total billed charges,85% of total billed charges,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.5,50,,15.6,percent of total billed charges,50% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,15.6,40,,12.48,percent of total billed charges,40% of total billed charges,4971.94,6623,
BICARB CONCENTRATE 4 GAL,4202989,CDM,270,RC,,,OUTPATIENT,,,44,26.4,,37.4,85,,29.92,Percent of total billed charges,85% of total billed charges,22,50,,17.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22,50,,17.6,percent of total billed charges,50% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,14.06,31.95,,11.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.72,38,,13.376,percent of total billed charges,38% of total billed charges,17.6,40,,14.08,percent of total billed charges,40% of total billed charges,4972.94,6624,
TABLO CARTRIDGES AND STRAWS BUNDLE,4202990,CDM,270,RC,,,OUTPATIENT,,,138,82.8,,117.3,85,,93.84,Percent of total billed charges,85% of total billed charges,69,50,,55.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,69,50,,55.2,percent of total billed charges,50% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,52.44,38,,41.952,percent of total billed charges,38% of total billed charges,55.2,40,,44.16,percent of total billed charges,40% of total billed charges,4973.94,6625,
FOGARTY ARTERIAL EMBOLECTOMY CATHETER 5FR,4202991,CDM,270,RC,,,OUTPATIENT,,,96,57.6,,81.6,85,,65.28,Percent of total billed charges,85% of total billed charges,48,50,,38.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,48,50,,38.4,percent of total billed charges,50% of total billed charges,30.67,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,30.67,31.95,,24.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.48,38,,29.184,percent of total billed charges,38% of total billed charges,38.4,40,,30.72,percent of total billed charges,40% of total billed charges,4974.94,6626,
4F SECURACATH U1.4,4202993,CDM,270,RC,,,OUTPATIENT,,,88,52.8,,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44,50,,35.2,percent of total billed charges,50% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.44,38,,26.752,percent of total billed charges,38% of total billed charges,35.2,40,,28.16,percent of total billed charges,40% of total billed charges,4975.94,6627,
PICO 14 - 15 X 20 CM,4202994,CDM,270,RC,,,OUTPATIENT,,,582,349.2,,494.7,85,,395.76,Percent of total billed charges,85% of total billed charges,291,50,,232.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,291,50,,232.8,percent of total billed charges,50% of total billed charges,185.95,31.95,,148.76,percent of total billed charges,31.95% of total billed charges,185.95,31.95,,148.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,221.16,38,,176.928,percent of total billed charges,38% of total billed charges,232.8,40,,186.24,percent of total billed charges,40% of total billed charges,4976.94,6628,
PICO 14 - 20 X 20 CM,4202995,CDM,270,RC,,,OUTPATIENT,,,582,349.2,,494.7,85,,395.76,Percent of total billed charges,85% of total billed charges,291,50,,232.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,291,50,,232.8,percent of total billed charges,50% of total billed charges,185.95,31.95,,148.76,percent of total billed charges,31.95% of total billed charges,185.95,31.95,,148.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,221.16,38,,176.928,percent of total billed charges,38% of total billed charges,232.8,40,,186.24,percent of total billed charges,40% of total billed charges,4977.94,6629,
BUTTERFLY 25GX3/4 W/LUER ADAPTER,4202997,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4978.94,6630,
SENHANCE ULTRASONIC DISSECTOR,4202998,CDM,270,RC,,,OUTPATIENT,,,1100,660,,935,85,,748,Percent of total billed charges,85% of total billed charges,550,50,,440,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,550,50,,440,percent of total billed charges,50% of total billed charges,351.45,31.95,,281.16,percent of total billed charges,31.95% of total billed charges,351.45,31.95,,281.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,418,38,,334.4,percent of total billed charges,38% of total billed charges,440,40,,352,percent of total billed charges,40% of total billed charges,4979.94,6631,
RENASYS 4X2.8 ADHESIVE GEL PATCH HYDROGEL,4202999,CDM,270,RC,,,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,10.4,percent of total billed charges,50% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,7.904,percent of total billed charges,38% of total billed charges,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,4980.94,6632,
CLEARIFY VISUALIZATION SYSTEM,4203000,CDM,270,RC,,,OUTPATIENT,,,181,108.6,,153.85,85,,123.08,Percent of total billed charges,85% of total billed charges,90.5,50,,72.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90.5,50,,72.4,percent of total billed charges,50% of total billed charges,57.83,31.95,,46.264,percent of total billed charges,31.95% of total billed charges,57.83,31.95,,46.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.78,38,,55.024,percent of total billed charges,38% of total billed charges,72.4,40,,57.92,percent of total billed charges,40% of total billed charges,4981.94,6633,
SUTURE 4.0 PROLENE NON-ABSORB 26MM 30/75CM,4203001,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,4.56,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,4982.94,6634,
DISPOSABLE PACING CABLE EXTERNAL PACEMAKER,4203002,CDM,270,RC,,,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,120,50,,96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,120,50,,96,percent of total billed charges,50% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,91.2,38,,72.96,percent of total billed charges,38% of total billed charges,96,40,,76.8,percent of total billed charges,40% of total billed charges,4983.94,6635,
CATHETER SILICONE 12FR 10CC LF,4203004,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4984.94,6636,
3 LINE TUBING FOR EVA INSUFFLATION SYSTEM,4203005,CDM,270,RC,,,OUTPATIENT,,,220,132,,187,85,,149.6,Percent of total billed charges,85% of total billed charges,110,50,,88,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,110,50,,88,percent of total billed charges,50% of total billed charges,70.29,31.95,,56.232,percent of total billed charges,31.95% of total billed charges,70.29,31.95,,56.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,83.6,38,,66.88,percent of total billed charges,38% of total billed charges,88,40,,70.4,percent of total billed charges,40% of total billed charges,4985.94,6637,
MASK PEDIATRIC NON-REBREATHER,4203006,CDM,270,RC,,,OUTPATIENT,,,19,11.4,,16.15,85,,12.92,Percent of total billed charges,85% of total billed charges,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,9.5,50,,7.6,percent of total billed charges,50% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.22,38,,5.776,percent of total billed charges,38% of total billed charges,7.6,40,,6.08,percent of total billed charges,40% of total billed charges,4986.94,6638,
RANGER FLUID WARMING SET,4203007,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,4987.94,6639,
PICC LINE COVER MEDIUM BLACK,4203008,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4988.94,6640,
PICC LINE COVER LARGE BLACK,4203009,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4989.94,6641,
PICC LINE COVER XLARGE BLACK,4203010,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4990.94,6642,
PICC LINE COVER OLIVE M,4203011,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4991.94,6643,
PICC LINE COVER OLIVE L,4203012,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4992.94,6644,
PICC LINE COVER OLIVE XL,4203013,CDM,270,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,4993.94,6645,
STOPCOCK 3-WAY LL/SPIN,4203014,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,4994.94,6646,
COLLAR EXTRICATION STIFNECK BABY NO-NECK CERVICAL,4203016,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,4995.94,6647,
COLLAR EXTRICATION MINI PERFIT ACE PEDIATRIC CERVICAL,4203017,CDM,270,RC,,,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,16,50,,12.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16,50,,12.8,percent of total billed charges,50% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.16,38,,9.728,percent of total billed charges,38% of total billed charges,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,4996.94,6648,
PURACOL ULTRA POWDER COLLAGEN WOUND DRESSING 1G,4203018,CDM,272,RC,,,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,30,percent of total billed charges,50% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.5,38,,22.8,percent of total billed charges,38% of total billed charges,30,40,,24,percent of total billed charges,40% of total billed charges,4997.94,6649,
OSCILLATORY PEP THERAPY DEVICE,4203020,CDM,271,RC,S8185,HCPCS,OUTPATIENT,,,84,50.4,,71.4,85,,57.12,Percent of total billed charges,85% of total billed charges,42,50,,33.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42,50,,33.6,percent of total billed charges,50% of total billed charges,29.53,35.15,,23.624,percent of total billed charges,35.15% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.92,38,,25.536,percent of total billed charges,38% of total billed charges,26.84,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,4998.94,6650,
RENASYS-F MED FOAM DRESSING KIT W/SOFT PORT,4203021,CDM,272,RC,,,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,60,50,,48,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,60,50,,48,percent of total billed charges,50% of total billed charges,38.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,38.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.6,38,,36.48,percent of total billed charges,38% of total billed charges,48,40,,38.4,percent of total billed charges,40% of total billed charges,4999.94,6651,
RENASYS-F LG FOAM DRESSING KIT W/SOFT PORT,4203022,CDM,272,RC,,,OUTPATIENT,,,145,87,,123.25,85,,98.6,Percent of total billed charges,85% of total billed charges,72.5,50,,58,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,72.5,50,,58,percent of total billed charges,50% of total billed charges,46.33,31.95,,37.064,percent of total billed charges,31.95% of total billed charges,46.33,31.95,,37.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.1,38,,44.08,percent of total billed charges,38% of total billed charges,58,40,,46.4,percent of total billed charges,40% of total billed charges,5000.94,6652,
RENASYS TOUCH 800ML CANISTER W/SOLIDIFIER,4203023,CDM,270,RC,,,OUTPATIENT,,,132,79.2,,112.2,85,,89.76,Percent of total billed charges,85% of total billed charges,66,50,,52.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,66,50,,52.8,percent of total billed charges,50% of total billed charges,42.17,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,42.17,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.16,38,,40.128,percent of total billed charges,38% of total billed charges,52.8,40,,42.24,percent of total billed charges,40% of total billed charges,5001.94,6653,
3M IOBAN INCISE DRAPE 20CM X 30CM,4203025,CDM,272,RC,,,OUTPATIENT,,,16,9.6,,13.6,85,,10.88,Percent of total billed charges,85% of total billed charges,8,50,,6.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8,50,,6.4,percent of total billed charges,50% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,5.11,31.95,,4.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.08,38,,4.864,percent of total billed charges,38% of total billed charges,6.4,40,,5.12,percent of total billed charges,40% of total billed charges,5002.94,6654,
CLAVE CONNECTOR MULTIDOSE VIAL ADAPTER,4203026,CDM,270,RC,,,OUTPATIENT,,,138,82.8,,117.3,85,,93.84,Percent of total billed charges,85% of total billed charges,69,50,,55.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,69,50,,55.2,percent of total billed charges,50% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,52.44,38,,41.952,percent of total billed charges,38% of total billed charges,55.2,40,,44.16,percent of total billed charges,40% of total billed charges,5003.94,6655,
COFLEX TLC 2 LAYER LONG,4203027,CDM,272,RC,,,OUTPATIENT,,,395,237,,335.75,85,,268.6,Percent of total billed charges,85% of total billed charges,197.5,50,,158,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,197.5,50,,158,percent of total billed charges,50% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.1,38,,120.08,percent of total billed charges,38% of total billed charges,158,40,,126.4,percent of total billed charges,40% of total billed charges,5004.94,6656,
RENASYS TOUCH 300ml CANISER W/SOLIDIFER,4203028,CDM,272,RC,,,OUTPATIENT,,,237,142.2,,201.45,85,,161.16,Percent of total billed charges,85% of total billed charges,118.5,50,,94.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,118.5,50,,94.8,percent of total billed charges,50% of total billed charges,75.72,31.95,,60.576,percent of total billed charges,31.95% of total billed charges,75.72,31.95,,60.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,90.06,38,,72.048,percent of total billed charges,38% of total billed charges,94.8,40,,75.84,percent of total billed charges,40% of total billed charges,5005.94,6657,
POWERGLIDE PRO MIDLINE CATHETER 20G X 8CM,4203029,CDM,272,RC,C1751,HCPCS,OUTPATIENT,,,304,182.4,,258.4,85,,206.72,Percent of total billed charges,85% of total billed charges,152,50,,121.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,152,50,,121.6,percent of total billed charges,50% of total billed charges,106.86,35.15,,85.488,percent of total billed charges,35.15% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,115.52,38,,92.416,percent of total billed charges,38% of total billed charges,97.13,31.95,,77.704,percent of total billed charges,31.95% of total billed charges,5006.94,6658,
POWERLINE 5F SL MI W/SCUFF,4203032,CDM,272,RC,,,OUTPATIENT,,,940,564,,799,85,,639.2,Percent of total billed charges,85% of total billed charges,470,50,,376,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,470,50,,376,percent of total billed charges,50% of total billed charges,300.33,31.95,,240.264,percent of total billed charges,31.95% of total billed charges,300.33,31.95,,240.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,357.2,38,,285.76,percent of total billed charges,38% of total billed charges,376,40,,300.8,percent of total billed charges,40% of total billed charges,5007.94,6659,
PICC PRESS INJECT SINGLE LUMEN 4.5FR X 55CM,4203038,CDM,272,RC,C1751,HCPCS,OUTPATIENT,,,613,367.8,,521.05,85,,416.84,Percent of total billed charges,85% of total billed charges,306.5,50,,245.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,306.5,50,,245.2,percent of total billed charges,50% of total billed charges,215.47,35.15,,172.376,percent of total billed charges,35.15% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,232.94,38,,186.352,percent of total billed charges,38% of total billed charges,195.85,31.95,,156.68,percent of total billed charges,31.95% of total billed charges,5008.94,6660,
PICC PRESS INJECT DOUBLE LUMEN 4.5FR X 55CM,4203039,CDM,272,RC,C1751,HCPCS,OUTPATIENT,,,711,426.6,,604.35,85,,483.48,Percent of total billed charges,85% of total billed charges,355.5,50,,284.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,355.5,50,,284.4,percent of total billed charges,50% of total billed charges,249.92,35.15,,199.936,percent of total billed charges,35.15% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,270.18,38,,216.144,percent of total billed charges,38% of total billed charges,227.16,31.95,,181.728,percent of total billed charges,31.95% of total billed charges,5009.94,6661,
MIDLINE PRESS INJECT SINGLE LUMEN 4.5FR X 15CM,4203040,CDM,272,RC,C1751,HCPCS,OUTPATIENT,,,338,202.8,,287.3,85,,229.84,Percent of total billed charges,85% of total billed charges,169,50,,135.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,169,50,,135.2,percent of total billed charges,50% of total billed charges,118.81,35.15,,95.048,percent of total billed charges,35.15% of total billed charges,152.08,31.95,,121.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.44,38,,102.752,percent of total billed charges,38% of total billed charges,107.99,31.95,,86.392,percent of total billed charges,31.95% of total billed charges,5010.94,6662,
GUIDEWIRE COATED NITINOL .018IN X 80CM,4203041,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,145,87,,152.25,105,,,case rate,pays based on 105% of threshold rate,72.5,50,,58,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,72.5,50,,58,percent of total billed charges,50% of total billed charges,50.97,35.15,,40.776,percent of total billed charges,35.15% of total billed charges,152.08,31.95,,121.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.1,38,,44.08,percent of total billed charges,38% of total billed charges,46.33,31.95,,37.064,percent of total billed charges,31.95% of total billed charges,5011.94,6663,
ARROW 4.5FR PICC INSERTION SET,4203042,CDM,278,RC,C1894,HCPCS,OUTPATIENT,,,147,88.2,,154.35,105,,,case rate,pays based on 105% of threshold rate,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,51.67,35.15,,41.336,percent of total billed charges,35.15% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.86,38,,44.688,percent of total billed charges,38% of total billed charges,46.97,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,5012.94,6664,
ARROW 5.5FR PICC INSERTION SET,4203043,CDM,278,RC,C1894,HCPCS,OUTPATIENT,,,147,88.2,,154.35,105,,,case rate,pays based on 105% of threshold rate,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,51.67,35.15,,41.336,percent of total billed charges,35.15% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.86,38,,44.688,percent of total billed charges,38% of total billed charges,46.97,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,5013.94,6665,
CATH BALLOON DILIT UROMAX ULTRA HIGH 12FR X 4CM,4203044,CDM,272,RC,C1726,HCPCS,OUTPATIENT,,,1055,633,,896.75,85,,717.4,Percent of total billed charges,85% of total billed charges,527.5,50,,422,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,527.5,50,,422,percent of total billed charges,50% of total billed charges,370.83,35.15,,296.664,percent of total billed charges,35.15% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,400.9,38,,320.72,percent of total billed charges,38% of total billed charges,337.07,31.95,,269.656,percent of total billed charges,31.95% of total billed charges,5014.94,6666,
STAPLER RELOAD ENDOPATH GREEN 60MM,4203045,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5015.94,6667,
Articulating Reloadable Fixation Device 3x8/1x5,4203046,CDM,272,RC,,,OUTPATIENT,,,1970,1182,,1674.5,85,,1339.6,Percent of total billed charges,85% of total billed charges,985,50,,788,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,985,50,,788,percent of total billed charges,50% of total billed charges,629.42,31.95,,503.536,percent of total billed charges,31.95% of total billed charges,629.42,31.95,,503.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,748.6,38,,598.88,percent of total billed charges,38% of total billed charges,788,40,,630.4,percent of total billed charges,40% of total billed charges,5016.94,6668,
CATH HEMODIALYSIS TITAN HD 15.5FR x 24CM,4203047,CDM,278,RC,C1750,HCPCS,OUTPATIENT,,,1144,686.4,,1201.2,105,,,case rate,pays based on 105% of threshold rate,572,50,,457.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,572,50,,457.6,percent of total billed charges,50% of total billed charges,402.12,35.15,,321.696,percent of total billed charges,35.15% of total billed charges,154,31.95,,123.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,434.72,38,,347.776,percent of total billed charges,38% of total billed charges,365.51,31.95,,292.408,percent of total billed charges,31.95% of total billed charges,5017.94,6669,
BOOT HEEL PROTECT PREVALON W/WEDGE,4203048,CDM,271,RC,A9283,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75,50,,60,percent of total billed charges,50% of total billed charges,52.73,35.15,,42.184,percent of total billed charges,35.15% of total billed charges,154,31.95,,123.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,5018.94,6670,
IRRISEPT JET LAVAGE W/0.05% CHG,4203050,CDM,270,RC,,,OUTPATIENT,,,245,147,,208.25,85,,166.6,Percent of total billed charges,85% of total billed charges,122.5,50,,98,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,122.5,50,,98,percent of total billed charges,50% of total billed charges,78.28,31.95,,62.624,percent of total billed charges,31.95% of total billed charges,78.28,31.95,,62.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,93.1,38,,74.48,percent of total billed charges,38% of total billed charges,98,40,,78.4,percent of total billed charges,40% of total billed charges,5019.94,6671,
TRAY HEYMON UROLOGIST,4203051,CDM,272,RC,,,OUTPATIENT,,,1400,840,,1190,85,,952,Percent of total billed charges,85% of total billed charges,700,50,,560,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,700,50,,560,percent of total billed charges,50% of total billed charges,447.3,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,447.3,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,532,38,,425.6,percent of total billed charges,38% of total billed charges,560,40,,448,percent of total billed charges,40% of total billed charges,5020.94,6672,
FILTER HYDROPHOBIC W/14 TUBING,4203052,CDM,270,RC,,,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,60.8,percent of total billed charges,38% of total billed charges,80,40,,64,percent of total billed charges,40% of total billed charges,5021.94,6673,
DILATOR CATH FEMALE 12F,4203053,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5022.94,6674,
DILATOR CATH FEMALE 14F,4203054,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5023.94,6675,
DILATOR CATH FEMALE 16F,4203055,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5024.94,6676,
DILATOR CATH FEMALE 18F,4203056,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5025.94,6677,
DILATOR CATH FEMALE 20F,4203057,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5026.94,6678,
DILATOR CATH FEMALE 22F,4203058,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5027.94,6679,
DILATOR CATH FEMALE 24F,4203059,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5028.94,6680,
DILATOR CATH FEMALE 26F,4203060,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5029.94,6681,
DILATOR CATH FEMALE 28F,4203061,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5030.94,6682,
DILATOR CATH FEMALE 30F,4203062,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5031.94,6683,
DILATOR CATH FEMALE 32F,4203063,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5032.94,6684,
DEVICE INFLATION ENCORE 26 INFLATOR 20ML SYR W/STPCK,4203064,CDM,270,RC,,,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,62.5,50,,50,percent of total billed charges,50% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.5,38,,38,percent of total billed charges,38% of total billed charges,50,40,,40,percent of total billed charges,40% of total billed charges,5033.94,6685,
PACK CYSTO II,4203065,CDM,270,RC,,,OUTPATIENT,,,155,93,,131.75,85,,105.4,Percent of total billed charges,85% of total billed charges,77.5,50,,62,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,77.5,50,,62,percent of total billed charges,50% of total billed charges,49.52,31.95,,39.616,percent of total billed charges,31.95% of total billed charges,49.52,31.95,,39.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,58.9,38,,47.12,percent of total billed charges,38% of total billed charges,62,40,,49.6,percent of total billed charges,40% of total billed charges,5034.94,6686,
BAG DRAIN URO DISP W/HOSE,4203068,CDM,270,RC,,,OUTPATIENT,,,140,84,,119,85,,95.2,Percent of total billed charges,85% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,70,50,,56,percent of total billed charges,50% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,56,40,,44.8,percent of total billed charges,40% of total billed charges,5035.94,6687,
CATH FOLEY COUNCIL RED LTX 18FR 5ML,4203069,CDM,272,RC,,,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,5036.94,6688,
CATH COUDE RED LTX 14FR 5CC,4203071,CDM,272,RC,,,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,20,percent of total billed charges,50% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,15.2,percent of total billed charges,38% of total billed charges,20,40,,16,percent of total billed charges,40% of total billed charges,5037.94,6689,
CATH FOLEY 3W 24FR 30CC,4203072,CDM,272,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,5038.94,6690,
CATH FOLEY PEDI LTX 10FR 3CC,4203073,CDM,272,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,10.64,percent of total billed charges,38% of total billed charges,14,40,,11.2,percent of total billed charges,40% of total billed charges,5039.94,6691,
CATH FOLEY 3W 18FR 10CC,4203074,CDM,272,RC,,,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.24,38,,14.592,percent of total billed charges,38% of total billed charges,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5040.94,6692,
SUP/EXT INSULIN INF PUMP SYR,4203076,CDM,272,RC,A4225,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,5.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.79,35.15,,7.032,percent of total billed charges,35.15% of total billed charges,15.66,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,3.28,100,,,fee schedule,100% of CMS custom fee schedule,9.5,38,,7.6,percent of total billed charges,38% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,5041.94,6693,
LASER FIBER SUPERPULSED TFL-FBX150BS,4203078,CDM,270,RC,,,OUTPATIENT,,,1215,729,,1032.75,85,,826.2,Percent of total billed charges,85% of total billed charges,607.5,50,,486,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,607.5,50,,486,percent of total billed charges,50% of total billed charges,388.19,31.95,,310.552,percent of total billed charges,31.95% of total billed charges,388.19,31.95,,310.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,461.7,38,,369.36,percent of total billed charges,38% of total billed charges,486,40,,388.8,percent of total billed charges,40% of total billed charges,5042.94,6694,
LASER FIBER SUPERPULSED TFL-FBX200BS,4203079,CDM,270,RC,,,OUTPATIENT,,,1215,729,,1032.75,85,,826.2,Percent of total billed charges,85% of total billed charges,607.5,50,,486,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,607.5,50,,486,percent of total billed charges,50% of total billed charges,388.19,31.95,,310.552,percent of total billed charges,31.95% of total billed charges,388.19,31.95,,310.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,461.7,38,,369.36,percent of total billed charges,38% of total billed charges,486,40,,388.8,percent of total billed charges,40% of total billed charges,5043.94,6695,
LASER FIBER SUPERPULSED TFL-FBX365S,4203080,CDM,270,RC,,,OUTPATIENT,,,1125,675,,956.25,85,,765,Percent of total billed charges,85% of total billed charges,562.5,50,,450,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,562.5,50,,450,percent of total billed charges,50% of total billed charges,359.44,31.95,,287.552,percent of total billed charges,31.95% of total billed charges,359.44,31.95,,287.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,427.5,38,,342,percent of total billed charges,38% of total billed charges,450,40,,360,percent of total billed charges,40% of total billed charges,5044.94,6696,
LASER FIBER SUPERPULSED TFL-FBX940S,4203081,CDM,270,RC,,,OUTPATIENT,,,1525,915,,1296.25,85,,1037,Percent of total billed charges,85% of total billed charges,762.5,50,,610,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,762.5,50,,610,percent of total billed charges,50% of total billed charges,487.24,31.95,,389.792,percent of total billed charges,31.95% of total billed charges,487.24,31.95,,389.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,579.5,38,,463.6,percent of total billed charges,38% of total billed charges,610,40,,488,percent of total billed charges,40% of total billed charges,5045.94,6697,
DEVICE/SHOULDER COMFORT FLOAT,4203082,CDM,270,RC,,,OUTPATIENT,,,165,99,,140.25,85,,112.2,Percent of total billed charges,85% of total billed charges,82.5,50,,66,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,82.5,50,,66,percent of total billed charges,50% of total billed charges,52.72,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,52.72,31.95,,42.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,62.7,38,,50.16,percent of total billed charges,38% of total billed charges,66,40,,52.8,percent of total billed charges,40% of total billed charges,5046.94,6698,
LAPAROSCOPIC SHAFT FORCEPS 5MMX45CM HALAR COATED,4203083,CDM,272,RC,,,OUTPATIENT,,,448,268.8,,380.8,85,,304.64,Percent of total billed charges,85% of total billed charges,224,50,,179.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,224,50,,179.2,percent of total billed charges,50% of total billed charges,143.14,31.95,,114.512,percent of total billed charges,31.95% of total billed charges,143.14,31.95,,114.512,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,170.24,38,,136.192,percent of total billed charges,38% of total billed charges,179.2,40,,143.36,percent of total billed charges,40% of total billed charges,5047.94,6699,
BRONCHOSCOPE BFLEX 2 SLIM 3.8,4203084,CDM,272,RC,,,OUTPATIENT,,,578,346.8,,491.3,85,,393.04,Percent of total billed charges,85% of total billed charges,289,50,,231.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,289,50,,231.2,percent of total billed charges,50% of total billed charges,184.67,31.95,,147.736,percent of total billed charges,31.95% of total billed charges,184.67,31.95,,147.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,219.64,38,,175.712,percent of total billed charges,38% of total billed charges,231.2,40,,184.96,percent of total billed charges,40% of total billed charges,5048.94,6700,
BRONCHOSCOPE BFLEX 2 REGULAR 5.0,4203085,CDM,272,RC,,,OUTPATIENT,,,578,346.8,,491.3,85,,393.04,Percent of total billed charges,85% of total billed charges,289,50,,231.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,289,50,,231.2,percent of total billed charges,50% of total billed charges,184.67,31.95,,147.736,percent of total billed charges,31.95% of total billed charges,184.67,31.95,,147.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,219.64,38,,175.712,percent of total billed charges,38% of total billed charges,231.2,40,,184.96,percent of total billed charges,40% of total billed charges,5049.94,6701,
CATH FOLEY 2W 5CC 14FR SILICONE BARDEX,4203087,CDM,272,RC,A4344,HCPCS,OUTPATIENT,,,31,18.6,,26.35,85,,21.08,Percent of total billed charges,85% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,10.9,35.15,,8.72,percent of total billed charges,35.15% of total billed charges,156.56,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,21.84,100,,,fee schedule,100% of CMS custom fee schedule,11.78,38,,9.424,percent of total billed charges,38% of total billed charges,9.9,31.95,,7.92,percent of total billed charges,31.95% of total billed charges,5050.94,6702,
CATH FOLEY 2W 5CC 22FR SILICONE BARDEX,4203088,CDM,272,RC,A4344,HCPCS,OUTPATIENT,,,31,18.6,,26.35,85,,21.08,Percent of total billed charges,85% of total billed charges,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15.5,50,,12.4,percent of total billed charges,50% of total billed charges,10.9,35.15,,8.72,percent of total billed charges,35.15% of total billed charges,158.47,31.95,,126.776,percent of total billed charges,31.95% of total billed charges,21.84,100,,,fee schedule,100% of CMS custom fee schedule,11.78,38,,9.424,percent of total billed charges,38% of total billed charges,9.9,31.95,,7.92,percent of total billed charges,31.95% of total billed charges,5051.94,6703,
ENDOTRACH HLDR ANCHORFAST GUARD SLCT,4203089,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,5052.94,6704,
MAT MOBILE TRANSFER M2 39x81,4203091,CDM,270,RC,,,OUTPATIENT,,,203,121.8,,172.55,85,,138.04,Percent of total billed charges,85% of total billed charges,101.5,50,,81.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,101.5,50,,81.2,percent of total billed charges,50% of total billed charges,64.86,31.95,,51.888,percent of total billed charges,31.95% of total billed charges,64.86,31.95,,51.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,77.14,38,,61.712,percent of total billed charges,38% of total billed charges,81.2,40,,64.96,percent of total billed charges,40% of total billed charges,5053.94,6705,
UROLIFT 2 IMPLANT CARTRIDGE,4203092,CDM,272,RC,,,OUTPATIENT,,,2150,1290,,1827.5,85,,1462,Percent of total billed charges,85% of total billed charges,1075,50,,860,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1075,50,,860,percent of total billed charges,50% of total billed charges,686.93,31.95,,549.544,percent of total billed charges,31.95% of total billed charges,686.93,31.95,,549.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,817,38,,653.6,percent of total billed charges,38% of total billed charges,860,40,,688,percent of total billed charges,40% of total billed charges,5054.94,6706,
UROLIFT 2 ATC IMPLANT CARTRIDGE,4203093,CDM,272,RC,,,OUTPATIENT,,,2400,1440,,2040,85,,1632,Percent of total billed charges,85% of total billed charges,1200,50,,960,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1200,50,,960,percent of total billed charges,50% of total billed charges,766.8,31.95,,613.44,percent of total billed charges,31.95% of total billed charges,766.8,31.95,,613.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,912,38,,729.6,percent of total billed charges,38% of total billed charges,960,40,,768,percent of total billed charges,40% of total billed charges,5055.94,6707,
UROLIFT 2 DELIVERY HANDLE W/SCOPE SEAL,4203094,CDM,272,RC,,,OUTPATIENT,,,2150,1290,,1827.5,85,,1462,Percent of total billed charges,85% of total billed charges,1075,50,,860,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1075,50,,860,percent of total billed charges,50% of total billed charges,686.93,31.95,,549.544,percent of total billed charges,31.95% of total billed charges,686.93,31.95,,549.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,817,38,,653.6,percent of total billed charges,38% of total billed charges,860,40,,688,percent of total billed charges,40% of total billed charges,5056.94,6708,
CATH MALE EXTERNAL PRIMOFIT,4203095,CDM,272,RC,A4349,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,29.88,35.15,,23.904,percent of total billed charges,35.15% of total billed charges,158.47,31.95,,126.776,percent of total billed charges,31.95% of total billed charges,2.74,100,,,fee schedule,100% of CMS custom fee schedule,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,5057.94,6709,
FORCEP BIOPSY ENDOJAW LRG CAPACITY SINGLE USE,4203096,CDM,272,RC,,,OUTPATIENT,,,47,28.2,,39.95,85,,31.96,Percent of total billed charges,85% of total billed charges,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,23.5,50,,18.8,percent of total billed charges,50% of total billed charges,15.02,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,15.02,31.95,,12.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.86,38,,14.288,percent of total billed charges,38% of total billed charges,18.8,40,,15.04,percent of total billed charges,40% of total billed charges,5058.94,6710,
CATH FEMALE EXTERNAL PRIMAFIT,4203098,CDM,272,RC,A4328,HCPCS,OUTPATIENT,,,62,37.2,,52.7,85,,42.16,Percent of total billed charges,85% of total billed charges,31,50,,24.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,31,50,,24.8,percent of total billed charges,50% of total billed charges,21.79,35.15,,17.432,percent of total billed charges,35.15% of total billed charges,159.11,31.95,,127.288,percent of total billed charges,31.95% of total billed charges,14.24,100,,,fee schedule,100% of CMS custom fee schedule,23.56,38,,18.848,percent of total billed charges,38% of total billed charges,19.81,31.95,,15.848,percent of total billed charges,31.95% of total billed charges,5059.94,6711,
FORCEP BIOPSY PIRANHA 3FR 1.1MMX115CM SCISSOR HANDLE,4203102,CDM,272,RC,,,OUTPATIENT,,,1285,771,,1092.25,85,,873.8,Percent of total billed charges,85% of total billed charges,642.5,50,,514,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,642.5,50,,514,percent of total billed charges,50% of total billed charges,410.56,31.95,,328.448,percent of total billed charges,31.95% of total billed charges,410.56,31.95,,328.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,488.3,38,,390.64,percent of total billed charges,38% of total billed charges,514,40,,411.2,percent of total billed charges,40% of total billed charges,5060.94,6712,
SUPER XL ENEMA SYS,4203103,CDM,270,RC,,,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,5061.94,6713,
POUCH FLUID COLLECTION W/DRAIN PORT 20x20,4203104,CDM,272,RC,,,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,21,50,,16.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,21,50,,16.8,percent of total billed charges,50% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,12.768,percent of total billed charges,38% of total billed charges,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,5062.94,6714,
STENT URETERAL PERCUFLEX PLUS 7FR 22CM DBL PGTL TPR LG,4203105,CDM,278,RC,C2617,HCPCS,OUTPATIENT,,,305,183,,320.25,105,,,case rate,pays based on 105% of threshold rate,152.5,50,,122,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,152.5,50,,122,percent of total billed charges,50% of total billed charges,107.21,35.15,,85.768,percent of total billed charges,35.15% of total billed charges,1597.5,31.95,,1278,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,115.9,38,,92.72,percent of total billed charges,38% of total billed charges,97.45,31.95,,77.96,percent of total billed charges,31.95% of total billed charges,5063.94,6715,
POWDER SURGICEL ABSORB HEMOSTATIC,4203106,CDM,272,RC,,,OUTPATIENT,,,625,375,,531.25,85,,425,Percent of total billed charges,85% of total billed charges,312.5,50,,250,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,312.5,50,,250,percent of total billed charges,50% of total billed charges,199.69,31.95,,159.752,percent of total billed charges,31.95% of total billed charges,199.69,31.95,,159.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,237.5,38,,190,percent of total billed charges,38% of total billed charges,250,40,,200,percent of total billed charges,40% of total billed charges,5064.94,6716,
APPLICATOR SURGICEL ABSORB HEMOSTAT PWDR ENDO,4203107,CDM,272,RC,,,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,62.5,50,,50,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,62.5,50,,50,percent of total billed charges,50% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.5,38,,38,percent of total billed charges,38% of total billed charges,50,40,,40,percent of total billed charges,40% of total billed charges,5065.94,6717,
PEG PULL KIT 24FR 5.5MM STD,4203108,CDM,270,RC,,,OUTPATIENT,,,330,198,,280.5,85,,224.4,Percent of total billed charges,85% of total billed charges,165,50,,132,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,165,50,,132,percent of total billed charges,50% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,132,40,,105.6,percent of total billed charges,40% of total billed charges,5066.94,6718,
EZ-Spray Atomization Device 60cc w/7' O2 Tubing,4203109,CDM,270,RC,,,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,47.5,50,,38,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47.5,50,,38,percent of total billed charges,50% of total billed charges,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,36.1,38,,28.88,percent of total billed charges,38% of total billed charges,38,40,,30.4,percent of total billed charges,40% of total billed charges,5067.94,6719,
CHOLANGIOGRAPHY SET 4FR E LUMEN,4203110,CDM,272,RC,,,OUTPATIENT,,,320,192,,272,85,,217.6,Percent of total billed charges,85% of total billed charges,160,50,,128,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,160,50,,128,percent of total billed charges,50% of total billed charges,102.24,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,102.24,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.6,38,,97.28,percent of total billed charges,38% of total billed charges,128,40,,102.4,percent of total billed charges,40% of total billed charges,5068.94,6720,
SURGICAL IRRIGATION SOLUTION 500ML,4203112,CDM,272,RC,,,OUTPATIENT,,,378,226.8,,321.3,85,,257.04,Percent of total billed charges,85% of total billed charges,189,50,,151.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,189,50,,151.2,percent of total billed charges,50% of total billed charges,120.77,31.95,,96.616,percent of total billed charges,31.95% of total billed charges,120.77,31.95,,96.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,143.64,38,,114.912,percent of total billed charges,38% of total billed charges,151.2,40,,120.96,percent of total billed charges,40% of total billed charges,5069.94,6721,
SPONGE SURGIFOAM 10MM,4203114,CDM,272,RC,,,OUTPATIENT,,,135,81,,114.75,85,,91.8,Percent of total billed charges,85% of total billed charges,67.5,50,,54,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,67.5,50,,54,percent of total billed charges,50% of total billed charges,43.13,31.95,,34.504,percent of total billed charges,31.95% of total billed charges,43.13,31.95,,34.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,51.3,38,,41.04,percent of total billed charges,38% of total billed charges,54,40,,43.2,percent of total billed charges,40% of total billed charges,5070.94,6722,
Angiocath IV Cath 14G x 3.25,4203115,CDM,272,RC,,,OUTPATIENT,,,53,31.8,,45.05,85,,36.04,Percent of total billed charges,85% of total billed charges,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,26.5,50,,21.2,percent of total billed charges,50% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,16.93,31.95,,13.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.14,38,,16.112,percent of total billed charges,38% of total billed charges,21.2,40,,16.96,percent of total billed charges,40% of total billed charges,5071.94,6723,
KIT PICC ARROWG+ARD AM 2-LUMEN 5.5FR X 55CM,4203116,CDM,272,RC,,,OUTPATIENT,,,545,327,,463.25,85,,370.6,Percent of total billed charges,85% of total billed charges,272.5,50,,218,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,272.5,50,,218,percent of total billed charges,50% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,207.1,38,,165.68,percent of total billed charges,38% of total billed charges,218,40,,174.4,percent of total billed charges,40% of total billed charges,5072.94,6724,
KIT PICC ARROWG+ARD AM 1-LUMEN 4.5FR X 55CM,4203117,CDM,272,RC,,,OUTPATIENT,,,525,315,,446.25,85,,357,Percent of total billed charges,85% of total billed charges,262.5,50,,210,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,262.5,50,,210,percent of total billed charges,50% of total billed charges,167.74,31.95,,134.192,percent of total billed charges,31.95% of total billed charges,167.74,31.95,,134.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,199.5,38,,159.6,percent of total billed charges,38% of total billed charges,210,40,,168,percent of total billed charges,40% of total billed charges,5073.94,6725,
KIT CENTRAL VENOUS AGBA PI JACC 1-L 4.5FR X 20CM,4203118,CDM,272,RC,,,OUTPATIENT,,,434,260.4,,368.9,85,,295.12,Percent of total billed charges,85% of total billed charges,217,50,,173.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,217,50,,173.6,percent of total billed charges,50% of total billed charges,138.66,31.95,,110.928,percent of total billed charges,31.95% of total billed charges,138.66,31.95,,110.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,164.92,38,,131.936,percent of total billed charges,38% of total billed charges,173.6,40,,138.88,percent of total billed charges,40% of total billed charges,5074.94,6726,
KIT CENTRAL VENOUS AGBA PI JACC 1-L 4.5FR X 15CM,4203119,CDM,272,RC,,,OUTPATIENT,,,434,260.4,,368.9,85,,295.12,Percent of total billed charges,85% of total billed charges,217,50,,173.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,217,50,,173.6,percent of total billed charges,50% of total billed charges,138.66,31.95,,110.928,percent of total billed charges,31.95% of total billed charges,138.66,31.95,,110.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,164.92,38,,131.936,percent of total billed charges,38% of total billed charges,173.6,40,,138.88,percent of total billed charges,40% of total billed charges,5075.94,6727,
SUTURE FIBERWIRE #5 38IN BLUE W/NDL 48MM 1/2 CIRCLE,4203120,CDM,272,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,5076.94,6728,
SUTURE FIBERWIRE #2 38IN BLUE W/NDL 36.6MM 1/2 CIRCLE,4203121,CDM,272,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,5077.94,6729,
DISSECTOR LAPAROSCOPIC INSERT MARYLAND 5MMX45CM,4203122,CDM,272,RC,,,OUTPATIENT,,,920,552,,782,85,,625.6,Percent of total billed charges,85% of total billed charges,460,50,,368,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,460,50,,368,percent of total billed charges,50% of total billed charges,293.94,31.95,,235.152,percent of total billed charges,31.95% of total billed charges,293.94,31.95,,235.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,349.6,38,,279.68,percent of total billed charges,38% of total billed charges,368,40,,294.4,percent of total billed charges,40% of total billed charges,5078.94,6730,
MESH VICRYL KNITTED UD 6x6,4203123,CDM,278,RC,C1781,HCPCS,OUTPATIENT,,,675,405,,708.75,105,,,case rate,pays based on 105% of threshold rate,337.5,50,,270,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,337.5,50,,270,percent of total billed charges,50% of total billed charges,237.26,35.15,,189.808,percent of total billed charges,35.15% of total billed charges,1725.3,31.95,,1380.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,256.5,38,,205.2,percent of total billed charges,38% of total billed charges,215.66,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,5079.94,6731,
CATH INJECTION GOLD PROBE BIPOLAR 210CM 7FR 25GA,4203124,CDM,272,RC,,,OUTPATIENT,,,1050,630,,892.5,85,,714,Percent of total billed charges,85% of total billed charges,525,50,,420,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,525,50,,420,percent of total billed charges,50% of total billed charges,335.48,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,335.48,31.95,,268.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,399,38,,319.2,percent of total billed charges,38% of total billed charges,420,40,,336,percent of total billed charges,40% of total billed charges,5080.94,6732,
QINFLOW WARRIOR LITE COMPACT DISP UNIT,4203125,CDM,272,RC,,,OUTPATIENT,,,215,129,,182.75,85,,146.2,Percent of total billed charges,85% of total billed charges,107.5,50,,86,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,107.5,50,,86,percent of total billed charges,50% of total billed charges,68.69,31.95,,54.952,percent of total billed charges,31.95% of total billed charges,68.69,31.95,,54.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,81.7,38,,65.36,percent of total billed charges,38% of total billed charges,86,40,,68.8,percent of total billed charges,40% of total billed charges,5081.94,6733,
OT Hot/Cold Pack Application Charge,4300001,CDM,430,RC,97010,HCPCS,OUTPATIENT,,,38,22.8,GP,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,10.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,15.2,40,,12.16,percent of total billed charges,40% of total billed charges,5082.94,6734,
OT Hot/Cold Pack Application Charge,4300001,CDM,430,RC,97010,HCPCS,OUTPATIENT,,,38,22.8,GP,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,10.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,15.2,40,,12.16,percent of total billed charges,40% of total billed charges,5083.94,6735,
"OT Hot, Cold Pack Assistant Units",4300001,CDM,430,RC,97010,HCPCS,OUTPATIENT,,,38,22.8,GP,32.3,85,,25.84,Percent of total billed charges,85% of total billed charges,10.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,15.2,40,,12.16,percent of total billed charges,40% of total billed charges,5084.94,6736,
Mechanical Traction Charge,4300002,CDM,421,RC,97012,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,42.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,42.31,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5085.94,6737,
PT ELECTRIC STIMULATION THERAPY UNATTENDED,4300003,CDM,421,RC,97014,HCPCS,OUTPATIENT,,,45,27,GP,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,40.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,18,40,,14.4,percent of total billed charges,40% of total billed charges,5086.94,6738,
Unattended Electrical Therapy Charge,4300003,CDM,421,RC,97014,HCPCS,OUTPATIENT,,,45,27,GP,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,40.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,18,40,,14.4,percent of total billed charges,40% of total billed charges,5087.94,6739,
PT Whirlpool Full Body Charge,4300004,CDM,421,RC,97022,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5088.94,6740,
Whirlpool Full Body Charge,4300004,CDM,421,RC,97022,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5089.94,6741,
"PT Whirlpool, Fluidotherapy Units",4300004,CDM,421,RC,97022,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5090.94,6742,
97022 WHIRLPOOL CHARGE,4300004,CDM,421,RC,97022,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5091.94,6743,
"PT Whirlpool, Fluidotherapy Assistant Units",4300004,CDM,421,RC,97022,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5092.94,6744,
ULTRAVIOLET THERAPY,4300005,CDM,421,RC,97028,HCPCS,OUTPATIENT,,,26,15.6,GP,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,5093.94,6745,
ULTRAVIOLET THERAPY,4300005,CDM,421,RC,97028,HCPCS,OUTPATIENT,,,26,15.6,GP,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,5094.94,6746,
Ultaviolet Charge,4300005,CDM,421,RC,97028,HCPCS,OUTPATIENT,,,26,15.6,GP,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,5095.94,6747,
PT Paraffin Assistant Units,4300005,CDM,421,RC,97028,HCPCS,OUTPATIENT,,,26,15.6,GP,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,5096.94,6748,
PT ELECTRIC CURRENT THERAPY,4300006,CDM,421,RC,97033,HCPCS,OUTPATIENT,,,90,54,GP,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,36,40,,28.8,percent of total billed charges,40% of total billed charges,5097.94,6749,
PT ELECTRIC CURRENT THERAPY,4300006,CDM,421,RC,97033,HCPCS,OUTPATIENT,,,90,54,GP,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,36,40,,28.8,percent of total billed charges,40% of total billed charges,5098.94,6750,
PT Iontophoresis Assistant Units,4300006,CDM,421,RC,97033,HCPCS,OUTPATIENT,,,90,54,GP,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,36,40,,28.8,percent of total billed charges,40% of total billed charges,5099.94,6751,
PT Contrast Bath Charges,4300007,CDM,421,RC,97034,HCPCS,OUTPATIENT,,,51,30.6,GP,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,5100.94,6752,
PT Contrast Bath Charges,4300007,CDM,421,RC,97034,HCPCS,OUTPATIENT,,,51,30.6,GP,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,5101.94,6753,
PT Contrast Bath Assistant Units,4300007,CDM,421,RC,97034,HCPCS,OUTPATIENT,,,51,30.6,GP,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,5102.94,6754,
PT Ultrasound Charges,4300008,CDM,421,RC,97035,HCPCS,OUTPATIENT,,,42,25.2,GP,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,5103.94,6755,
PT Ultrasound Charges,4300008,CDM,421,RC,97035,HCPCS,OUTPATIENT,,,42,25.2,GP,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,5104.94,6756,
PT Ultrasound Assistant Units,4300008,CDM,421,RC,97035,HCPCS,OUTPATIENT,,,42,25.2,GP,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,5105.94,6757,
97036 HYDROTHERAPY,4300009,CDM,421,RC,97036,HCPCS,OUTPATIENT,,,91,54.6,GP,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,64.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,64.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,29.07,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,36.4,40,,29.12,percent of total billed charges,40% of total billed charges,5106.94,6758,
PT Therapeutic Exercise Charges,4300010,CDM,421,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GP,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5107.94,6759,
97110 THERAPEUTIC EXER 15 MIN,4300010,CDM,421,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GP,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5108.94,6760,
97110 THERAPEUTIC EXER 15 MIN,4300010,CDM,421,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GP,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5109.94,6761,
PT Therapeutic Exercise Assistant Units,4300010,CDM,421,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GP,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5110.94,6762,
PT Gait Training Charges,4300011,CDM,421,RC,97116,HCPCS,OUTPATIENT,,,82,49.2,GP,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,32.8,40,,26.24,percent of total billed charges,40% of total billed charges,5111.94,6763,
97116 GAIT TRAINING CHARGE,4300011,CDM,421,RC,97116,HCPCS,OUTPATIENT,,,82,49.2,GP,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,32.8,40,,26.24,percent of total billed charges,40% of total billed charges,5112.94,6764,
97116 GAIT TRAINING CHARGE,4300011,CDM,421,RC,97116,HCPCS,OUTPATIENT,,,82,49.2,GP,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,32.8,40,,26.24,percent of total billed charges,40% of total billed charges,5113.94,6765,
PT Gait Training Assistant Units,4300011,CDM,421,RC,97116,HCPCS,OUTPATIENT,,,82,49.2,GP,69.7,85,,55.76,Percent of total billed charges,85% of total billed charges,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,70.09,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,26.2,31.95,,20.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,32.8,40,,26.24,percent of total billed charges,40% of total billed charges,5114.94,6766,
PT Massage Charge Units,4300012,CDM,421,RC,97124,HCPCS,OUTPATIENT,,,48,28.8,GP,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5115.94,6767,
PT Massage Charge Units,4300012,CDM,421,RC,97124,HCPCS,OUTPATIENT,,,48,28.8,GP,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5116.94,6768,
PT Massage Assistant Units,4300012,CDM,421,RC,97124,HCPCS,OUTPATIENT,,,48,28.8,GP,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5117.94,6769,
"PT Self Care, Home Management Charges",4300013,CDM,421,RC,97535,HCPCS,OUTPATIENT,,,99,59.4,GP,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,5118.94,6770,
"PT Self Care, Home Management Charges",4300013,CDM,421,RC,97535,HCPCS,OUTPATIENT,,,99,59.4,GP,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,5119.94,6771,
"PT Self Care, Home Management Assistant Units",4300013,CDM,421,RC,97535,HCPCS,OUTPATIENT,,,99,59.4,GP,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,5120.94,6772,
Orthotic Mgmt and Training Charges Initial Encounter,4300014,CDM,421,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,GP,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5121.94,6773,
"PT Orthotic Management, Train Units",4300014,CDM,421,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,GP,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5122.94,6774,
Orthotic Mgmt and Training Charges Initial Encounter,4300014,CDM,421,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,GP,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5123.94,6775,
PT Orthotic Mgmt/Train Est Assist Units,4300014,CDM,421,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,GP,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5124.94,6776,
PT EVAL LOW COMPLEX UNITS,4300015,CDM,424,RC,97161,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5125.94,6777,
BCE PT EVAL LOW COMPLEX UNITS,4300015,CDM,424,RC,97161,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5126.94,6778,
PT Low Complex Units,4300015,CDM,421,RC,97161,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5127.94,6779,
PT EVAL LOW COMPLEX UNITS,4300015,CDM,424,RC,97161,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5128.94,6780,
PT RE-EVAL EST PLAN CARE,4300016,CDM,424,RC,97164,HCPCS,OUTPATIENT,,,125,75,GP,106.25,85,,85,Percent of total billed charges,85% of total billed charges,158.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,158.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.42,110,,,fee schedule,110% of LA custom fee schedule,50.38,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,50.38,100,,,Fee Schedule,100% of LA custom fee schedule,5129.94,6781,
PT RE-EVAL EST PLAN CARE,4300016,CDM,424,RC,97164,HCPCS,OUTPATIENT,,,125,75,GP,106.25,85,,85,Percent of total billed charges,85% of total billed charges,158.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,158.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.42,110,,,fee schedule,110% of LA custom fee schedule,50.38,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,50.38,100,,,Fee Schedule,100% of LA custom fee schedule,5130.94,6782,
PT ELECTRIC STIMULATION ATTENDED,4300017,CDM,421,RC,97032,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5131.94,6783,
PT ELECTRIC STIMULATION ATTENDED,4300017,CDM,421,RC,97032,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5132.94,6784,
PT Attended E-Stim Assistant Units,4300017,CDM,421,RC,97032,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5133.94,6785,
PT Neuromuscular Reeducation Charges,4300018,CDM,421,RC,97112,HCPCS,OUTPATIENT,,,60,36,GP,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5134.94,6786,
PT Neuromuscular Reeducation Units,4300018,CDM,421,RC,97112,HCPCS,OUTPATIENT,,,60,36,GP,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5135.94,6787,
Neuromuscular Reeducation Charges - PT BCE,4300018,CDM,421,RC,97112,HCPCS,OUTPATIENT,,,60,36,GP,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5136.94,6788,
PT Neuromuscular Reeducation Assistant Units,4300018,CDM,421,RC,97112,HCPCS,OUTPATIENT,,,60,36,GP,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5137.94,6789,
Therapeutic Activities Charge,4300019,CDM,421,RC,97530,HCPCS,OUTPATIENT,,,80,48,GP,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5138.94,6790,
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN,4300019,CDM,421,RC,97530,HCPCS,OUTPATIENT,,,80,48,GP,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5139.94,6791,
Therapeutic Activities Charge,4300019,CDM,421,RC,97530,HCPCS,OUTPATIENT,,,80,48,GP,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5140.94,6792,
PT Therapeutic Activity Assistant Units,4300019,CDM,421,RC,97530,HCPCS,OUTPATIENT,,,80,48,GP,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5141.94,6793,
PT Sensory Integration Charges,4300021,CDM,421,RC,97533,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5142.94,6794,
PT Sensory Integration Charges,4300021,CDM,421,RC,97533,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5143.94,6795,
PT Sensory Integration Assistant Units,4300021,CDM,421,RC,97533,HCPCS,OUTPATIENT,,,65,39,GP,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.64,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5144.94,6796,
Wheelchair Management Charges,4300022,CDM,421,RC,97542,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5145.94,6797,
PT Wheelchair Management Units,4300022,CDM,421,RC,97542,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5146.94,6798,
PT Wheelchair Management Assistant Units,4300022,CDM,421,RC,97542,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5147.94,6799,
Joint Mobilization Charges,4300023,CDM,421,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GP,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5148.94,6800,
Manual Therapy Charge Units,4300024,CDM,421,RC,97140,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5149.94,6801,
MANUAL THERAPY,4300024,CDM,421,RC,97140,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5150.94,6802,
MANUAL THERAPY,4300024,CDM,421,RC,97140,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5151.94,6803,
PT Manual Therapy Assistant Units,4300024,CDM,421,RC,97140,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5152.94,6804,
OT RE-EVAL EST PLAN CARE,4300025,CDM,434,RC,97168,HCPCS,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,198.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,198.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.34,110,,,fee schedule,110% of LA custom fee schedule,47.58,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,47.58,100,,,Fee Schedule,100% of LA custom fee schedule,5153.94,6805,
OT RE-EVAL EST PLAN CARE,4300025,CDM,434,RC,97168,HCPCS,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,198.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,198.12,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.34,110,,,fee schedule,110% of LA custom fee schedule,47.58,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,47.58,100,,,Fee Schedule,100% of LA custom fee schedule,5154.94,6806,
Group Therapy Provided,4300026,CDM,433,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5155.94,6807,
ADL Training Charges,4300027,CDM,431,RC,97535,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,50,40,,40,percent of total billed charges,40% of total billed charges,5156.94,6808,
Tx of Speech/Lang/Voice/Comm/Auditory Chg,4300028,CDM,440,RC,92507,HCPCS,OUTPATIENT,,,180,108,GN,153,85,,122.4,Percent of total billed charges,85% of total billed charges,289.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,289.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.52,110,,,fee schedule,110% of LA custom fee schedule,49.56,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,49.56,100,,,Fee Schedule,100% of LA custom fee schedule,5157.94,6809,
Tx of Speech/Lang/Voice/Comm/Auditory Chg,4300028,CDM,440,RC,92507,HCPCS,OUTPATIENT,,,180,108,GN,153,85,,122.4,Percent of total billed charges,85% of total billed charges,289.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,289.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.52,110,,,fee schedule,110% of LA custom fee schedule,49.56,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,49.56,100,,,Fee Schedule,100% of LA custom fee schedule,5158.94,6810,
Tx of Speech/Lang/Voice/Comm/Auditory Chg,4300028,CDM,440,RC,92507,HCPCS,OUTPATIENT,,,180,108,GN,153,85,,122.4,Percent of total billed charges,85% of total billed charges,289.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,289.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.52,110,,,fee schedule,110% of LA custom fee schedule,49.56,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,49.56,100,,,Fee Schedule,100% of LA custom fee schedule,5159.94,6811,
Speech Sound Production Eval Charge,4300029,CDM,444,RC,92522,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,190.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,190.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5160.94,6812,
Speech Sound Production Eval Charge,4300029,CDM,444,RC,92522,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,190.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,190.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5161.94,6813,
Speech Sound Production Eval Charge,4300029,CDM,444,RC,92522,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,190.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,190.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5162.94,6814,
Speech Sound Prod w/ Language Charge,4300030,CDM,444,RC,92523,HCPCS,OUTPATIENT,,,175,105,GN,148.75,85,,119,Percent of total billed charges,85% of total billed charges,395.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,395.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5163.94,6815,
Speech Sound Prod w/ Language Charge,4300030,CDM,444,RC,92523,HCPCS,OUTPATIENT,,,175,105,GN,148.75,85,,119,Percent of total billed charges,85% of total billed charges,395.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,395.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5164.94,6816,
Speech Sound Production Eval Charge,4300030,CDM,444,RC,92523,HCPCS,OUTPATIENT,,,175,105,GN,148.75,85,,119,Percent of total billed charges,85% of total billed charges,395.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,395.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5165.94,6817,
Treatment of Swallowing Dysfunction,4300031,CDM,440,RC,92526,HCPCS,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,395.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,395.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,78,40,,62.4,percent of total billed charges,40% of total billed charges,5166.94,6818,
Treatment of Swallowing Dysfunction,4300031,CDM,440,RC,92526,HCPCS,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,395.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,395.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,78,40,,62.4,percent of total billed charges,40% of total billed charges,5167.94,6819,
Treatment of Swallowing Dysfunction,4300031,CDM,440,RC,92526,HCPCS,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,395.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,395.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,78,40,,62.4,percent of total billed charges,40% of total billed charges,5168.94,6820,
ST Evaluate Swallowing Function - CHAS,4300032,CDM,444,RC,92610,HCPCS,OUTPATIENT,,,285,171,,242.25,85,,193.8,Percent of total billed charges,85% of total billed charges,395.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,395.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.88,110,,,fee schedule,110% of LA custom fee schedule,37.16,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,37.16,100,,,Fee Schedule,100% of LA custom fee schedule,5169.94,6821,
Standardized Aphasia Assessment Charge,4300033,CDM,444,RC,96105,HCPCS,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,323.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,323.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,96,40,,76.8,percent of total billed charges,40% of total billed charges,5170.94,6822,
Aphasia Assesment Per Hour,4300033,CDM,444,RC,96105,HCPCS,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,323.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,323.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,96,40,,76.8,percent of total billed charges,40% of total billed charges,5171.94,6823,
PT Moderate Complex Units,4300034,CDM,424,RC,97162,HCPCS,OUTPATIENT,,,185,111,GP,157.25,85,,125.8,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5172.94,6824,
PT Moderate Complex Units,4300034,CDM,424,RC,97162,HCPCS,OUTPATIENT,,,185,111,GP,157.25,85,,125.8,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5173.94,6825,
PT EVAL MOD COMPLEXITY,4300034,CDM,424,RC,97162,HCPCS,OUTPATIENT,,,185,111,GP,157.25,85,,125.8,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5174.94,6826,
PT High Complex Units,4300035,CDM,424,RC,97163,HCPCS,OUTPATIENT,,,225,135,GP,191.25,85,,153,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5175.94,6827,
PT High Complex Units,4300035,CDM,424,RC,97163,HCPCS,OUTPATIENT,,,225,135,GP,191.25,85,,153,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5176.94,6828,
PT EVAL HIGH COMPLEXITY,4300035,CDM,424,RC,97163,HCPCS,OUTPATIENT,,,225,135,GP,191.25,85,,153,Percent of total billed charges,85% of total billed charges,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,215.54,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.93,110,,,fee schedule,110% of LA custom fee schedule,74.48,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,74.48,100,,,Fee Schedule,100% of LA custom fee schedule,5177.94,6829,
OT Low Complex Units,4300036,CDM,434,RC,97165,HCPCS,OUTPATIENT,,,160,96,GO,136,85,,108.8,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5178.94,6830,
OT Low Complex Units,4300036,CDM,434,RC,97165,HCPCS,OUTPATIENT,,,160,96,GO,136,85,,108.8,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5179.94,6831,
OT EVAL LOW COMPLEXITY,4300036,CDM,434,RC,97165,HCPCS,OUTPATIENT,,,160,96,GO,136,85,,108.8,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5180.94,6832,
OT Moderate Complex Units,4300037,CDM,431,RC,97166,HCPCS,OUTPATIENT,,,185,111,,157.25,85,,125.8,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5181.94,6833,
OT Moderate Complex Units,4300037,CDM,431,RC,97166,HCPCS,OUTPATIENT,,,185,111,,157.25,85,,125.8,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5182.94,6834,
OT EVAL MOD COMPLEXITY,4300037,CDM,434,RC,97166,HCPCS,OUTPATIENT,,,185,111,,157.25,85,,125.8,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5183.94,6835,
OT High Complex Units,4300038,CDM,434,RC,97167,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5184.94,6836,
OT High Complex Units,4300038,CDM,434,RC,97167,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5185.94,6837,
OT EVAL HIGH COMPLEXITY,4300038,CDM,434,RC,97167,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,229.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.59,110,,,fee schedule,110% of LA custom fee schedule,72.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,72.35,100,,,Fee Schedule,100% of LA custom fee schedule,5186.94,6838,
Neuromuscular Reeducation Charges,4300039,CDM,431,RC,97112,HCPCS,OUTPATIENT,,,60,36,GO,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5187.94,6839,
OT Neuromuscular Reeducation Units,4300039,CDM,431,RC,97112,HCPCS,OUTPATIENT,,,60,36,GO,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5188.94,6840,
Neuromuscular Reeducation Charges - OT BCE,4300039,CDM,431,RC,97112,HCPCS,OUTPATIENT,,,60,36,GO,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5189.94,6841,
OT Neuromuscular Reeducation Assistant Units,4300039,CDM,431,RC,97112,HCPCS,OUTPATIENT,,,60,36,GO,51,85,,40.8,Percent of total billed charges,85% of total billed charges,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,24,40,,19.2,percent of total billed charges,40% of total billed charges,5190.94,6842,
SPEECH THERAPY/GROUP CHARGE,4300040,CDM,443,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5191.94,6843,
SPEECH THERAPY/GROUP CHARGE,4300040,CDM,443,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5192.94,6844,
Group Therapy Provided,4300041,CDM,423,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5193.94,6845,
Group Therapy Charge,4300041,CDM,423,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5194.94,6846,
Group Therapy Provided,4300041,CDM,423,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5195.94,6847,
Group Therapy Provided,4300041,CDM,423,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5196.94,6848,
PT Group Therapy Assistant Units,4300041,CDM,423,RC,97150,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,5197.94,6849,
Therapeutic Activities Charges,4300042,CDM,431,RC,97530,HCPCS,OUTPATIENT,,,80,48,GO,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5198.94,6850,
OT THERAPEUTIC ACTIVITIES Charge,4300042,CDM,431,RC,97530,HCPCS,OUTPATIENT,,,80,48,GO,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5199.94,6851,
Therapeutic Activities Charges,4300042,CDM,431,RC,97530,HCPCS,OUTPATIENT,,,80,48,GO,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5200.94,6852,
OT Therapeutic Activities Assistant Units,4300042,CDM,431,RC,97530,HCPCS,OUTPATIENT,,,80,48,GO,68,85,,54.4,Percent of total billed charges,85% of total billed charges,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,82.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.69,110,,,fee schedule,110% of LA custom fee schedule,13.35,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,13.35,100,,,Fee Schedule,100% of LA custom fee schedule,5201.94,6853,
Cognitive Skills Development Charges 1st 15 Mins ST,4300044,CDM,441,RC,97129,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5202.94,6854,
SPEECH Cognitive Skills Charge 1st 15 Mins,4300044,CDM,441,RC,97129,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5203.94,6855,
SLP Cognitive Function Medicare Charge 1st 15 Mins,4300044,CDM,441,RC,97129,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5204.94,6856,
Therapeutic Exercise Charges,4300045,CDM,431,RC,97535,HCPCS,OUTPATIENT,,,99,59.4,GO,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,5205.94,6857,
"OT Self Care, Home Management Charges",4300045,CDM,431,RC,97535,HCPCS,OUTPATIENT,,,99,59.4,GO,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,5206.94,6858,
"OT Self Care, Home Mgmt Assistant Units",4300045,CDM,431,RC,97535,HCPCS,OUTPATIENT,,,99,59.4,GO,84.15,85,,67.32,Percent of total billed charges,85% of total billed charges,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,84.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,31.63,31.95,,25.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.6,40,,31.68,percent of total billed charges,40% of total billed charges,5207.94,6859,
PT Physical Performance Test Charges,4300046,CDM,421,RC,97750,HCPCS,OUTPATIENT,,,100,60,GP,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5208.94,6860,
PT Physical Performance Test Charges,4300046,CDM,421,RC,97750,HCPCS,OUTPATIENT,,,100,60,GP,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5209.94,6861,
PT PHYSICAL PERFORMANCE TEST,4300046,CDM,421,RC,97750,HCPCS,OUTPATIENT,,,100,60,GP,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5210.94,6862,
PT Physical Performance Assistant Test,4300046,CDM,421,RC,97750,HCPCS,OUTPATIENT,,,100,60,GP,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5211.94,6863,
OT PHYSICAL PERFORMANCE TEST,4300047,CDM,431,RC,97750,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5212.94,6864,
OT Physical Performance Test,4300047,CDM,431,RC,97750,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5213.94,6865,
OT Physical Performance Test Charges,4300047,CDM,431,RC,97750,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5214.94,6866,
OT Physical Performance Test Assistant Units,4300047,CDM,431,RC,97750,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,40,40,,32,percent of total billed charges,40% of total billed charges,5215.94,6867,
Prosthetic Training Charges Initial,4300048,CDM,421,RC,97761,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5216.94,6868,
PT PROSTHETIC TRAIN INITIAL,4300048,CDM,421,RC,97761,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5217.94,6869,
PT PROSTHETIC TRAIN INITIAL,4300048,CDM,421,RC,97761,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5218.94,6870,
Prosthetic Training Charges Initial,4300048,CDM,421,RC,97761,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5219.94,6871,
"PT Prosthetic Management, Train Assistant Units",4300048,CDM,421,RC,97761,HCPCS,OUTPATIENT,,,160,96,GP,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5220.94,6872,
PT 16030 DRESSING,4300050,CDM,421,RC,16030,HCPCS,OUTPATIENT,,,375,225,GP,318.75,85,,255,Percent of total billed charges,85% of total billed charges,187.5,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,187.5,50,,150,percent of total billed charges,50% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,150,40,,120,percent of total billed charges,40% of total billed charges,5221.94,6873,
Therapeutic Exercise Charges,4300051,CDM,431,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GO,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5222.94,6874,
OT THERAPEUTIC EXERCISE 15 MIN,4300051,CDM,431,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GO,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5223.94,6875,
Therapeutic Exercise Charges,4300051,CDM,431,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GO,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5224.94,6876,
OT Therapeutic Exercise Assistant Units,4300051,CDM,431,RC,97110,HCPCS,OUTPATIENT,,,92,55.2,GO,78.2,85,,62.56,Percent of total billed charges,85% of total billed charges,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.83,110,,,fee schedule,110% of LA custom fee schedule,16.21,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.21,100,,,Fee Schedule,100% of LA custom fee schedule,5225.94,6877,
Paraffin Bath Charge,4300052,CDM,431,RC,97018,HCPCS,OUTPATIENT,,,45,27,GO,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,18,40,,14.4,percent of total billed charges,40% of total billed charges,5226.94,6878,
OT PARAFFIN BATH THERAPY,4300052,CDM,431,RC,97018,HCPCS,OUTPATIENT,,,45,27,GO,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,18,40,,14.4,percent of total billed charges,40% of total billed charges,5227.94,6879,
OT PARAFFIN BATH THERAPY,4300052,CDM,431,RC,97018,HCPCS,OUTPATIENT,,,45,27,GO,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,18,40,,14.4,percent of total billed charges,40% of total billed charges,5228.94,6880,
OT Paraffin Bath Assistant Units,4300052,CDM,431,RC,97018,HCPCS,OUTPATIENT,,,45,27,GO,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,18,40,,14.4,percent of total billed charges,40% of total billed charges,5229.94,6881,
"OT Whirlpool, Fluidtherapy Units",4300053,CDM,431,RC,97022,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5230.94,6882,
OT WHIRLPOOL THERAPY,4300053,CDM,431,RC,97022,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5231.94,6883,
"OT Whirlpool, Fluidotherapy Assistant Units",4300053,CDM,431,RC,97022,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,40.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5232.94,6884,
OT DIATHERMY EG MICROWAVE,4300054,CDM,431,RC,97024,HCPCS,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,14.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,5233.94,6885,
Attended E-Stim Charges,4300055,CDM,431,RC,97032,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5234.94,6886,
OT ELECTRICAL STIMULATION,4300055,CDM,431,RC,G0283,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,49.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5235.94,6887,
OT ELECTRICAL STIMULATION,4300055,CDM,431,RC,97032,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5236.94,6888,
OT Attended E-Stim Assistant Units,4300055,CDM,431,RC,97032,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,45.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5237.94,6889,
OT Iontophoresis Units,4300056,CDM,431,RC,97033,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,36,40,,28.8,percent of total billed charges,40% of total billed charges,5238.94,6890,
OT ELECTRIC CURRENT THERAPY,4300056,CDM,431,RC,97033,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,36,40,,28.8,percent of total billed charges,40% of total billed charges,5239.94,6891,
OT Iontophoresis Assistant Units,4300056,CDM,431,RC,97033,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,36,40,,28.8,percent of total billed charges,40% of total billed charges,5240.94,6892,
OT Contrast Bath Units,4300057,CDM,431,RC,97034,HCPCS,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,5241.94,6893,
OT CONTRAST BATH THERAPY,4300057,CDM,431,RC,97034,HCPCS,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,5242.94,6894,
OT Contrast Bath Assistant Units,4300057,CDM,431,RC,97034,HCPCS,OUTPATIENT,,,51,30.6,,43.35,85,,34.68,Percent of total billed charges,85% of total billed charges,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,39.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,16.29,31.95,,13.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,20.4,40,,16.32,percent of total billed charges,40% of total billed charges,5243.94,6895,
OT Ultrasound Units,4300058,CDM,431,RC,97035,HCPCS,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,5244.94,6896,
OT ULTRASOUND THERAPY,4300058,CDM,431,RC,97035,HCPCS,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,5245.94,6897,
OT Ultrasound Assistant Units,4300058,CDM,431,RC,97035,HCPCS,OUTPATIENT,,,42,25.2,,35.7,85,,28.56,Percent of total billed charges,85% of total billed charges,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,34.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,16.8,40,,13.44,percent of total billed charges,40% of total billed charges,5246.94,6898,
Massage Charge Units,4300059,CDM,431,RC,97124,HCPCS,OUTPATIENT,,,48,28.8,GO,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5247.94,6899,
OT MASSAGE THERAPY,4300059,CDM,431,RC,97124,HCPCS,OUTPATIENT,,,48,28.8,GO,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5248.94,6900,
OT MASSAGE THERAPY,4300059,CDM,431,RC,97124,HCPCS,OUTPATIENT,,,48,28.8,GO,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5249.94,6901,
OT Massage Assistant Units,4300059,CDM,431,RC,97124,HCPCS,OUTPATIENT,,,48,28.8,GO,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,5250.94,6902,
Manual Therapy Charge Units,4300060,CDM,431,RC,97140,HCPCS,OUTPATIENT,,,65,39,GO,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5251.94,6903,
OT MANUAL THERAPY,4300060,CDM,431,RC,97140,HCPCS,OUTPATIENT,,,65,39,GO,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5252.94,6904,
OT Unattended E-Stim Units,4300060,CDM,431,RC,97140,HCPCS,OUTPATIENT,,,65,39,GO,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5253.94,6905,
OT Unattended E-Stim Assistant Units,4300060,CDM,431,RC,97140,HCPCS,OUTPATIENT,,,65,39,GO,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,74.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5254.94,6906,
Orthotic Mgmt and Training Charges,4300061,CDM,431,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5255.94,6907,
OT ORTHOTIC MGMT AND TRAINING,4300061,CDM,431,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5256.94,6908,
OT ORTHOTIC MGMT AND TRAINING,4300061,CDM,431,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5257.94,6909,
"OT Orthotic Management, Train Assistant Units",4300061,CDM,431,RC,97760,HCPCS,OUTPATIENT,,,109,65.4,,92.65,85,,74.12,Percent of total billed charges,85% of total billed charges,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,106.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.57,110,,,fee schedule,110% of LA custom fee schedule,22.34,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,22.34,100,,,Fee Schedule,100% of LA custom fee schedule,5258.94,6910,
"OT Prosthetic Management, Train Units",4300062,CDM,431,RC,97761,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5259.94,6911,
OT PROSTHETIC TRAINING Initial,4300062,CDM,431,RC,97761,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5260.94,6912,
"OT Prosthetic Management, Train Assistant Units",4300062,CDM,431,RC,97761,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,98.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.99,110,,,fee schedule,110% of LA custom fee schedule,19.99,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,19.99,100,,,Fee Schedule,100% of LA custom fee schedule,5261.94,6913,
"OT ROM, Extremity Units",4300067,CDM,431,RC,95851,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,5262.94,6914,
OT ROM MEASUREMENTS,4300067,CDM,431,RC,95851,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,5263.94,6915,
"OT ROM, Extremity Assistant Units",4300067,CDM,431,RC,95851,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,5264.94,6916,
OT Wheelchair Management Units,4300068,CDM,431,RC,97542,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5265.94,6917,
OT WHEELCHAIR MNGMENT TRAINING,4300068,CDM,431,RC,97542,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5266.94,6918,
OT Wheelchair Management Assistant Units,4300068,CDM,431,RC,97542,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,79.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5267.94,6919,
PT PARAFFIN BATH THERAPY,4300069,CDM,421,RC,97018,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,17.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,18,40,,14.4,percent of total billed charges,40% of total billed charges,5268.94,6920,
PT DIATHERMY EG MICROWAVE,4300070,CDM,421,RC,97024,HCPCS,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,14.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,5269.94,6921,
PT COMMUNITY/WORK REINTEGRATION,4300071,CDM,421,RC,97537,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,77.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,50,40,,40,percent of total billed charges,40% of total billed charges,5270.94,6922,
PT COMMUNITY/WORK REINTEGRATION,4300071,CDM,421,RC,97537,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,77.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,50,40,,40,percent of total billed charges,40% of total billed charges,5271.94,6923,
"PT Community,Work Reintegration Assistant Units",4300071,CDM,421,RC,97537,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,77.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,77.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,50,40,,40,percent of total billed charges,40% of total billed charges,5272.94,6924,
PT RMVL DEVITAL TIS 20 CM/<,4300072,CDM,421,RC,97597,HCPCS,OUTPATIENT,,,612,367.2,,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,244.8,40,,195.84,percent of total billed charges,40% of total billed charges,5273.94,6925,
PT RMVL DEVITAL TIS 20 CM/<,4300072,CDM,421,RC,97597,HCPCS,OUTPATIENT,,,612,367.2,,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,244.8,40,,195.84,percent of total billed charges,40% of total billed charges,5274.94,6926,
PT Select Debrid WO Anes Assistant Units,4300072,CDM,421,RC,97597,HCPCS,OUTPATIENT,,,612,367.2,,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,244.8,40,,195.84,percent of total billed charges,40% of total billed charges,5275.94,6927,
PT RMVL DEVITAL TIS ADDL 20CM/<,4300073,CDM,421,RC,97598,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,213.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,213.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5276.94,6928,
PT RMVL DEVITAL TIS ADDL 20CM/<,4300073,CDM,421,RC,97598,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,213.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,213.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5277.94,6929,
PT Sel Debrid WO Anes > 20cm Asst Units,4300073,CDM,421,RC,97598,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,213.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,213.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5278.94,6930,
PT ROM MEASUREMENTS,4300078,CDM,421,RC,95851,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,5279.94,6931,
PT ROM MEASUREMENTS,4300078,CDM,421,RC,95851,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,5280.94,6932,
PT ROM MEASUREMENTS,4300078,CDM,421,RC,95851,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,5281.94,6933,
PT ROM Measure Extremity Trunk No Hands Assistant Units,4300078,CDM,421,RC,95851,HCPCS,OUTPATIENT,,,32,19.2,,27.2,85,,21.76,Percent of total billed charges,85% of total billed charges,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,10.22,31.95,,8.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,12.8,40,,10.24,percent of total billed charges,40% of total billed charges,5282.94,6934,
SPEECH / HEARING THERAPY,4300079,CDM,441,RC,92508,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,47.5,50,,38,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47.5,50,,38,percent of total billed charges,50% of total billed charges,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,38,40,,30.4,percent of total billed charges,40% of total billed charges,5283.94,6935,
SPEECH / HEARING THERAPY,4300079,CDM,441,RC,92508,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,47.5,50,,38,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,47.5,50,,38,percent of total billed charges,50% of total billed charges,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,38,40,,30.4,percent of total billed charges,40% of total billed charges,5284.94,6936,
EVALUATION OF SPEECH FLUENCY,4300080,CDM,440,RC,92521,HCPCS,OUTPATIENT,,,435,261,,369.75,85,,295.8,Percent of total billed charges,85% of total billed charges,234.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,234.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5285.94,6937,
EVALUATION OF SPEECH FLUENCY,4300080,CDM,440,RC,92521,HCPCS,OUTPATIENT,,,435,261,,369.75,85,,295.8,Percent of total billed charges,85% of total billed charges,234.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,234.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.41,110,,,fee schedule,110% of LA custom fee schedule,66.74,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,66.74,100,,,Fee Schedule,100% of LA custom fee schedule,5286.94,6938,
COGNITIVE TEST BY HC PRO,4300081,CDM,918,RC,96125,HCPCS,OUTPATIENT,,,472,283.2,,401.2,85,,320.96,Percent of total billed charges,85% of total billed charges,444.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,444.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.8,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,150.8,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,200,100,,,case rate,pays based on per visit rate,188.8,40,,151.04,percent of total billed charges,40% of total billed charges,5287.94,6939,
COGNITIVE TEST BY HC PRO,4300081,CDM,918,RC,96125,HCPCS,OUTPATIENT,,,472,283.2,,401.2,85,,320.96,Percent of total billed charges,85% of total billed charges,444.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,444.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.8,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,150.8,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,200,100,,,case rate,pays based on per visit rate,188.8,40,,151.04,percent of total billed charges,40% of total billed charges,5288.94,6940,
OT Cognitive Skills Charge 1st 15 Mins Medicare,4300082,CDM,431,RC,97129,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5289.94,6941,
PT Cognitive Function 1st 15 mins Medicare,4300083,CDM,421,RC,97129,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5290.94,6942,
PT Cognitive Skills Charge Medicare,4300083,CDM,421,RC,97129,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,80.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5291.94,6943,
SPEECH Cognitive Skills Charge Medicare,4300084,CDM,441,RC,G0515,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5292.94,6944,
SPEECH Cognitive Skills Charge Medicare,4300084,CDM,441,RC,G0515,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,28,40,,22.4,percent of total billed charges,40% of total billed charges,5293.94,6945,
OT Orthotic Mgmt/Train Establish Rehab Units,4300085,CDM,421,RC,97763,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,43.25,110,,,fee schedule,110% of LA custom fee schedule,39.32,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.32,100,,,Fee Schedule,100% of LA custom fee schedule,5294.94,6946,
PT Orthotic management/training Subsequent,4300085,CDM,421,RC,97763,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,43.25,110,,,fee schedule,110% of LA custom fee schedule,39.32,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.32,100,,,Fee Schedule,100% of LA custom fee schedule,5295.94,6947,
OT Orthotic Mgmt/Train Est Assist Units,4300085,CDM,421,RC,97763,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,43.25,110,,,fee schedule,110% of LA custom fee schedule,39.32,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,39.32,100,,,Fee Schedule,100% of LA custom fee schedule,5296.94,6948,
OT Cognitive Skills Charge Ea Addl 15 min Medicare,4300090,CDM,431,RC,97130,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,76.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5297.94,6949,
PT Cognitive Skills Charge Ea Addl 15 min Medicare,4300091,CDM,421,RC,97130,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,76.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5298.94,6950,
SPEECH Cognitive Skills Charge Ea Addl 15 min Medicare,4300092,CDM,441,RC,97130,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,76.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,76.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,26,40,,20.8,percent of total billed charges,40% of total billed charges,5299.94,6951,
"PT Dry Needling, 1-2 Muscles Units",4300100,CDM,420,RC,20560,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5300.94,6952,
NEEDLE INSERTION W/O INJECTION 1-2 MUSCLES,4300100,CDM,420,RC,20560,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,30,40,,24,percent of total billed charges,40% of total billed charges,5301.94,6953,
"PT Dry Needling, 3+ Muscles Units",4300101,CDM,420,RC,20561,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,34,40,,27.2,percent of total billed charges,40% of total billed charges,5302.94,6954,
NEEDLE INSERTION W/O INJECTION 3+ MUSCLES,4300101,CDM,420,RC,20561,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,80,100,,,case rate,pays based on per visit rate,34,40,,27.2,percent of total billed charges,40% of total billed charges,5303.94,6955,
94625 PHY/QHP OP PULM REHAB W/O MNTR,4300125,CDM,948,RC,94625,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125,100,,,case rate,pays based on per visit rate,60,40,,48,percent of total billed charges,40% of total billed charges,5304.94,6956,
94626 PHY/QHP OP PULM REHAB W/MNTR,4300126,CDM,948,RC,94626,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125,100,,,case rate,pays based on per visit rate,60,40,,48,percent of total billed charges,40% of total billed charges,5305.94,6957,
PTT,4320319,CDM,305,RC,85730,HCPCS,OUTPATIENT,,,34,20.4,,28.9,85,,23.12,Percent of total billed charges,85% of total billed charges,27.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,6.61,110,,,fee schedule,110% of LA custom fee schedule,6.01,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,12.92,38,,10.336,percent of total billed charges,38% of total billed charges,6.01,100,,,Fee Schedule,100% of LA custom fee schedule,5306.94,6958,
K-WIRE 1.25X150mm SS,4400000,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,13,7.8,,13.65,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.57,35.15,,3.656,percent of total billed charges,35.15% of total billed charges,1857.89,31.95,,1486.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.94,38,,3.952,percent of total billed charges,38% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,5307.94,6959,
K-WIRE 1.6X150mm SS,4400001,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,50,30,,52.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.58,35.15,,14.064,percent of total billed charges,35.15% of total billed charges,1.61,31.95,,1.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,15.2,percent of total billed charges,38% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,5308.94,6960,
K-WIRE TROCAR POINT,4400002,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,65,39,,68.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.85,35.15,,18.28,percent of total billed charges,35.15% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,5309.94,6961,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING,4400003,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,33.3,19.98,,34.97,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,11.7,35.15,,9.36,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.65,38,,10.12,percent of total billed charges,38% of total billed charges,10.64,31.95,,8.512,percent of total billed charges,31.95% of total billed charges,5310.94,6962,
WASHER T8  T10 SCREWS 2.4mm / 2.7mm / 3.5mm,4400004,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,94,56.4,,98.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,33.04,35.15,,26.432,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35.72,38,,28.576,percent of total billed charges,38% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,5311.94,6963,
LOCKING SCREW T8 FULL THREAD 2.4mm/L8mm,4400005,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,345,207,,362.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,121.27,35.15,,97.016,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.1,38,,104.88,percent of total billed charges,38% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,5312.94,6964,
LOCKING SCREW T8 FULL THREAD 2.4mm/L10mm,4400006,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5313.94,6965,
LOCKING SCREW T8 FULL THREAD 2.4mm / L12mm,4400007,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5314.94,6966,
LOCKING SCREW T8 FULL THREAD 2.4mm / L14mm,4400008,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,477,286.2,,500.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,167.67,35.15,,134.136,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,181.26,38,,145.008,percent of total billed charges,38% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,5315.94,6967,
LOCKING SCREW T8 FULL THREAD 2.4mm / L16mm,4400009,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,5316.94,6968,
LOCKING SCREW T8 FULL THREAD 2.4mm / L18mm,4400010,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,477,286.2,,500.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,167.67,35.15,,134.136,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,181.26,38,,145.008,percent of total billed charges,38% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,5317.94,6969,
LOCKING SCREW T8 FULL THREAD 2.4mm / L20mm,4400011,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,477,286.2,,500.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,167.67,35.15,,134.136,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,181.26,38,,145.008,percent of total billed charges,38% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,5318.94,6970,
LOCKING SCREW T8 FULL THREAD 2.4mm / L22mm,4400012,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,5319.94,6971,
LOCKING SCREW T8 FULL THREAD 2.4mm / L24mm,4400013,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5320.94,6972,
LOCKING SCREW T8 FULL THREAD 2.4mm / L26mm,4400014,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,165.82,31.95,,132.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5321.94,6973,
LOCKING SCREW T8 FULL THREAD 2.4mm / L28mm,4400015,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,166.14,31.95,,132.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5322.94,6974,
LOCKING SCREW T8 FULL THREAD 2.4mm / L30mm,4400016,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5323.94,6975,
LOCKING SCREW T8 FULL THREAD 2.4mm / L32mm,4400017,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5324.94,6976,
LOCKING SCREW T8 FULL THREAD 2.4mm / L34mm,4400018,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5325.94,6977,
LOCKING SCREW T8 FULL THREAD 2.4mm / L36mm,4400019,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,172.21,31.95,,137.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5326.94,6978,
LOCKING SCREW T8 FULL THREAD 2.4mm / L38mm,4400020,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,17.44,31.95,,13.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5327.94,6979,
BONE SCREW T8 FULL THREAD 2.4mm / L8mm,4400021,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5328.94,6980,
BONE SCREW T8 FULL THREAD 2.4mm/L10mm,4400022,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,174,104.4,,182.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.16,35.15,,48.928,percent of total billed charges,35.15% of total billed charges,174.45,31.95,,139.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.12,38,,52.896,percent of total billed charges,38% of total billed charges,55.59,31.95,,44.472,percent of total billed charges,31.95% of total billed charges,5329.94,6981,
BONE SCREW T8 FULL THREAD 2.4mm / L12mm,4400023,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5330.94,6982,
BONE SCREW T8 FULL THREAD 2.4mm / L14mm,4400024,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,230,138,,241.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,64.68,percent of total billed charges,35.15% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,5331.94,6983,
BONE SCREW T8 FULL THREAD 2.4mm / L16mm,4400025,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,279,167.4,,292.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,98.07,35.15,,78.456,percent of total billed charges,35.15% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,106.02,38,,84.816,percent of total billed charges,38% of total billed charges,89.14,31.95,,71.312,percent of total billed charges,31.95% of total billed charges,5332.94,6984,
BONE SCREW T8 FULL THREAD 2.4mm / L18mm,4400026,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5333.94,6985,
BONE SCREW T8 FULL THREAD 2.4mm / L20mm,4400027,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5334.94,6986,
BONE SCREW T8 FULL THREAD 2.4mm / L22mm,4400028,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5335.94,6987,
BONE SCREW T8 FULL THREAD 2.4mm / L24mm,4400029,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5336.94,6988,
BONE SCREW T8 FULL THREAD 2.4mm / L26mm,4400030,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,232,139.2,,243.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.55,35.15,,65.24,percent of total billed charges,35.15% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,88.16,38,,70.528,percent of total billed charges,38% of total billed charges,74.12,31.95,,59.296,percent of total billed charges,31.95% of total billed charges,5337.94,6989,
BONE SCREW T8 FULL THREAD 2.4mm / L28mm,4400031,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,176.68,31.95,,141.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5338.94,6990,
BONE SCREW T8 FULL THREAD 2.4mm / L30mm,4400032,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5339.94,6991,
BONE SCREW T8 FULL THREAD 2.4mm / L32mm,4400033,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5340.94,6992,
BONE SCREW T8 FULL THREAD 2.4mm / L34mm,4400034,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5341.94,6993,
BONE SCREW T8 FULL THREAD 2.4mm / L36mm,4400035,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5342.94,6994,
BONE SCREW T8 FULL THREAD 2.4mm / L38mm,4400036,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5343.94,6995,
LOCKING SCREW T8 FULL THREAD 2.7mm / L8mm,4400037,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,178.92,31.95,,143.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5344.94,6996,
LOCKING SCREW T8 FULL THREAD 2.7mm / L10mm,4400038,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,178.92,31.95,,143.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5345.94,6997,
LOCKING SCREW T8 FULL THREAD 2.7mm / L12mm,4400039,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,178.92,31.95,,143.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,5346.94,6998,
LOCKING SCREW T8 FULL THREAD 2.7mm / L14mm,4400040,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,5347.94,6999,
LOCKING SCREW T8 FULL THREAD 2.7mm / L16mm,4400041,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5348.94,7000,
LOCKING SCREW T8 FULL THREAD 2.7mm / L18mm,4400042,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,5349.94,7001,
LOCKING SCREW T8 FULL THREAD 2.7mm / L20mm,4400043,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,188.51,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,5350.94,7002,
LOCKING SCREW T8 FULL THREAD 2.7mm / L22mm,4400044,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,189.46,31.95,,151.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,5351.94,7003,
LOCKING SCREW T8 FULL THREAD 2.7mm / L24mm,4400045,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,189.78,31.95,,151.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5352.94,7004,
LOCKING SCREW T8 FULL THREAD 2.7mm / L26mm,4400046,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,320,192,,336,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.48,35.15,,89.984,percent of total billed charges,35.15% of total billed charges,189.78,31.95,,151.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.6,38,,97.28,percent of total billed charges,38% of total billed charges,102.24,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,5353.94,7005,
LOCKING SCREW T8 FULL THREAD 2.7mm / L28mm,4400047,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,2210.3,31.95,,1768.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5354.94,7006,
LOCKING SCREW T8 FULL THREAD 2.7mm / L30mm,4400048,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5355.94,7007,
LOCKING SCREW T8 FULL THREAD 2.7mm / L32mm,4400049,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5356.94,7008,
LOCKING SCREW T8 FULL THREAD 2.7mm / L34mm,4400050,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5357.94,7009,
LOCKING SCREW T8 FULL THREAD 2.7mm / L36mm,4400051,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5358.94,7010,
LOCKING SCREW T8 FULL THREAD 2.7mm / L38mm,4400052,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5359.94,7011,
LOCKING SCREW T8 FULL THREAD 2.7mm / L40mm,4400053,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5360.94,7012,
LOCKING SCREW T8 FULL THREAD 2.7mm / L45mm,4400054,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5361.94,7013,
LOCKING SCREW T8 FULL THREAD 2.7mm / L50mm,4400055,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42.15,25.29,,44.26,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.82,35.15,,11.856,percent of total billed charges,35.15% of total billed charges,193.3,31.95,,154.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,16.02,38,,12.816,percent of total billed charges,38% of total billed charges,13.47,31.95,,10.776,percent of total billed charges,31.95% of total billed charges,5362.94,7014,
BONE SCREW T8 FULL THREAD 2.7mm / L8mm,4400056,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,174,104.4,,182.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.16,35.15,,48.928,percent of total billed charges,35.15% of total billed charges,199.69,31.95,,159.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.12,38,,52.896,percent of total billed charges,38% of total billed charges,55.59,31.95,,44.472,percent of total billed charges,31.95% of total billed charges,5363.94,7015,
BONE SCREW T8 FULL THREAD 2.7mm / L10mm,4400057,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,200.01,31.95,,160.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5364.94,7016,
BONE SCREW T8 FULL THREAD 2.7mm / L12mm,4400058,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,230,138,,241.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,64.68,percent of total billed charges,35.15% of total billed charges,204.48,31.95,,163.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,5365.94,7017,
BONE SCREW T8 FULL THREAD 2.7mm / L14mm,4400059,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,319,191.4,,334.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.13,35.15,,89.704,percent of total billed charges,35.15% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.22,38,,96.976,percent of total billed charges,38% of total billed charges,101.92,31.95,,81.536,percent of total billed charges,31.95% of total billed charges,5366.94,7018,
BONE SCREW T8 FULL THREAD 2.7mm / L16mm,4400060,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,263,157.8,,276.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,92.44,35.15,,73.952,percent of total billed charges,35.15% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,99.94,38,,79.952,percent of total billed charges,38% of total billed charges,84.03,31.95,,67.224,percent of total billed charges,31.95% of total billed charges,5367.94,7019,
BONE SCREW T8 FULL THREAD 2.7mm / L18mm,4400061,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,230,138,,241.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,64.68,percent of total billed charges,35.15% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,5368.94,7020,
BONE SCREW T8 FULL THREAD 2.7mm / L20mm,4400062,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,174,104.4,,182.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.16,35.15,,48.928,percent of total billed charges,35.15% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.12,38,,52.896,percent of total billed charges,38% of total billed charges,55.59,31.95,,44.472,percent of total billed charges,31.95% of total billed charges,5369.94,7021,
BONE SCREW T8 FULL THREAD 2.7mm / L22mm,4400063,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,260,156,,273,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,91.39,35.15,,73.112,percent of total billed charges,35.15% of total billed charges,21.09,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,98.8,38,,79.04,percent of total billed charges,38% of total billed charges,83.07,31.95,,66.456,percent of total billed charges,31.95% of total billed charges,5370.94,7022,
BONE SCREW T8 FULL THREAD 2.7mm / L24mm,4400064,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,230,138,,241.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,80.85,35.15,,64.68,percent of total billed charges,35.15% of total billed charges,21.73,31.95,,17.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,5371.94,7023,
BONE SCREW T8 FULL THREAD 2.7mm / L26mm,4400065,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,263,157.8,,276.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,92.44,35.15,,73.952,percent of total billed charges,35.15% of total billed charges,21.73,31.95,,17.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,99.94,38,,79.952,percent of total billed charges,38% of total billed charges,84.03,31.95,,67.224,percent of total billed charges,31.95% of total billed charges,5372.94,7024,
BONE SCREW T8 FULL THREAD 2.7mm / L28mm,4400066,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5373.94,7025,
BONE SCREW T8 FULL THREAD 2.7mm / L30mm,4400067,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,174,104.4,,182.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,61.16,35.15,,48.928,percent of total billed charges,35.15% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,66.12,38,,52.896,percent of total billed charges,38% of total billed charges,55.59,31.95,,44.472,percent of total billed charges,31.95% of total billed charges,5374.94,7026,
BONE SCREW T8 FULL THREAD 2.7mm / L32mm,4400068,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5375.94,7027,
BONE SCREW T8 FULL THREAD 2.7mm / L34mm,4400069,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5376.94,7028,
BONE SCREW T8 FULL THREAD 2.7mm / L36mm,4400070,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5377.94,7029,
BONE SCREW T8 FULL THREAD 2.7mm / L38mm,4400071,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,220.46,31.95,,176.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5378.94,7030,
BONE SCREW T8 FULL THREAD 2.7mm / L40mm,4400072,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,239,143.4,,250.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,84.01,35.15,,67.208,percent of total billed charges,35.15% of total billed charges,220.46,31.95,,176.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,90.82,38,,72.656,percent of total billed charges,38% of total billed charges,76.36,31.95,,61.088,percent of total billed charges,31.95% of total billed charges,5379.94,7031,
BONE SCREW T8 FULL THREAD 2.7mm / L45mm,4400073,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,223.65,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5380.94,7032,
BONE SCREW T8 FULL THREAD 2.7mm / L50mm,4400074,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,24.6,14.76,,25.83,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.65,35.15,,6.92,percent of total billed charges,35.15% of total billed charges,223.65,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.35,38,,7.48,percent of total billed charges,38% of total billed charges,7.86,31.95,,6.288,percent of total billed charges,31.95% of total billed charges,5381.94,7033,
LOCKING SCREW T10 FULL THREAD 2.7mm / L8mm,4400075,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5382.94,7034,
LOCKING SCREW T10 FULL THREAD 2.7mm / L10mm,4400076,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5383.94,7035,
LOCKING SCREW T10 FULL THREAD 2.7mm / L12mm,4400077,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5384.94,7036,
LOCKING SCREW T10 FULL THREAD 2.7mm / L14mm,4400078,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5385.94,7037,
LOCKING SCREW T10 FULL THREAD 2.7mm / L16mm,4400079,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5386.94,7038,
LOCKING SCREW T10 FULL THREAD 2.7mm / L18mm,4400080,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5387.94,7039,
LOCKING SCREW T10 FULL THREAD 2.7mm / L20mm,4400081,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5388.94,7040,
LOCKING SCREW T10 FULL THREAD 2.7mm / L22mm,4400082,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5389.94,7041,
LOCKING SCREW T10 FULL THREAD 2.7mm / L24mm,4400083,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5390.94,7042,
LOCKING SCREW T10 FULL THREAD 2.7mm / L26mm,4400084,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5391.94,7043,
LOCKING SCREW T10 FULL THREAD 2.7mm / L28mm,4400085,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5392.94,7044,
LOCKING SCREW T10 FULL THREAD 2.7mm / L30mm,4400086,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5393.94,7045,
LOCKING SCREW T10 FULL THREAD 2.7mm / L32mm,4400087,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5394.94,7046,
LOCKING SCREW T10 FULL THREAD 2.7mm / L34mm,4400088,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5395.94,7047,
LOCKING SCREW T10 FULL THREAD 2.7mm / L36mm,4400089,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5396.94,7048,
LOCKING SCREW T10 FULL THREAD 2.7mm / L38mm,4400090,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5397.94,7049,
LOCKING SCREW T10 FULL THREAD 2.7mm / L40mm,4400091,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5398.94,7050,
LOCKING SCREW T10 FULL THREAD 2.7mm / L42mm,4400092,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5399.94,7051,
LOCKING SCREW T10 FULL THREAD 2.7mm / L44mm,4400093,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5400.94,7052,
LOCKING SCREW T10 FULL THREAD 2.7mm / L46mm,4400094,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5401.94,7053,
LOCKING SCREW T10 FULL THREAD 2.7mm / L48mm,4400095,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5402.94,7054,
LOCKING SCREW T10 FULL THREAD 2.7mm / L50mm,4400096,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5403.94,7055,
LOCKING SCREW T10 FULL THREAD 2.7mm / L55mm,4400097,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5404.94,7056,
LOCKING SCREW T10 FULL THREAD 2.7mm / L60mm,4400098,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5405.94,7057,
LOCKING SCREW T10 FULL THREAD 2.7mm / L65mm,4400099,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5406.94,7058,
LOCKING SCREW T10 FULL THREAD 2.7mm / L70mm,4400100,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5407.94,7059,
BONE SCREW T10 FULL THREAD 2.7mm / L8mm,4400101,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,254,152.4,,266.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,89.28,35.15,,71.424,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,96.52,38,,77.216,percent of total billed charges,38% of total billed charges,81.15,31.95,,64.92,percent of total billed charges,31.95% of total billed charges,5408.94,7060,
BONE SCREW T10 FULL THREAD 2.7mm / L10mm,4400102,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,254,152.4,,266.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,89.28,35.15,,71.424,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,96.52,38,,77.216,percent of total billed charges,38% of total billed charges,81.15,31.95,,64.92,percent of total billed charges,31.95% of total billed charges,5409.94,7061,
BONE SCREW T10 FULL THREAD 2.7mm / L12mm,4400103,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,254,152.4,,266.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,89.28,35.15,,71.424,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,96.52,38,,77.216,percent of total billed charges,38% of total billed charges,81.15,31.95,,64.92,percent of total billed charges,31.95% of total billed charges,5410.94,7062,
BONE SCREW T10 FULL THREAD 2.7mm / L14mm,4400104,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5411.94,7063,
BONE SCREW T10 FULL THREAD 2.7mm / L16mm,4400105,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5412.94,7064,
BONE SCREW T10 FULL THREAD 2.7mm / L18mm,4400106,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5413.94,7065,
BONE SCREW T10 FULL THREAD 2.7mm / L20mm,4400107,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5414.94,7066,
BONE SCREW T10 FULL THREAD 2.7mm / L22mm,4400108,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,23.29,31.95,,18.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5415.94,7067,
BONE SCREW T10 FULL THREAD 2.7mm / L24mm,4400109,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,236.11,31.95,,188.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5416.94,7068,
BONE SCREW T10 FULL THREAD 2.7mm / L26mm,4400110,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5417.94,7069,
GAMMA 3 S NAIL RIGHT 10x420mm x 125,4400111,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5418.94,7070,
BONE SCREW T10 FULL THREAD 2.7mm / L30mm,4400112,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,237.71,31.95,,190.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5419.94,7071,
BONE SCREW T10 FULL THREAD 2.7mm / L32mm,4400113,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,238.67,31.95,,190.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5420.94,7072,
BONE SCREW T10 FULL THREAD 2.7mm / L34mm,4400114,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5421.94,7073,
BONE SCREW T10 FULL THREAD 2.7mm / L36mm,4400115,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,240.26,31.95,,192.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5422.94,7074,
BONE SCREW T10 FULL THREAD 2.7mm / L38mm,4400116,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,253.04,31.95,,202.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5423.94,7075,
BONE SCREW T10 FULL THREAD 2.7mm / L40mm,4400117,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5424.94,7076,
BONE SCREW T10 FULL THREAD 2.7mm / L42mm,4400118,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5425.94,7077,
BONE SCREW T10 FULL THREAD 2.7mm / L44mm,4400119,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5426.94,7078,
BONE SCREW T10 FULL THREAD 2.7mm / L46mm,4400120,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5427.94,7079,
BONE SCREW T10 FULL THREAD 2.7mm / L48mm,4400121,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5428.94,7080,
BONE SCREW T10 FULL THREAD 2.7mm / L50mm,4400122,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5429.94,7081,
BONE SCREW T10 FULL THREAD 2.7mm / L55mm,4400123,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5430.94,7082,
BONE SCREW T10 FULL THREAD 2.7mm / L60mm,4400124,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5431.94,7083,
BONE SCREW T10 FULL THREAD 2.7mm / L65mm,4400125,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,26.17,31.95,,20.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5432.94,7084,
BONE SCREW T10 FULL THREAD 2.7mm / L70mm,4400126,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,26.17,31.95,,20.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5433.94,7085,
LOCKING SCREW T10 FULL THREAD 3.5mm / L8mm,4400127,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,259.75,31.95,,207.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5434.94,7086,
LOCKING SCREW T10 FULL THREAD 3.5mm / L10mm,4400128,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,443,265.8,,465.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,155.71,35.15,,124.568,percent of total billed charges,35.15% of total billed charges,261.03,31.95,,208.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,168.34,38,,134.672,percent of total billed charges,38% of total billed charges,141.54,31.95,,113.232,percent of total billed charges,31.95% of total billed charges,5435.94,7087,
LOCKING SCREW T10 FULL THREAD 3.5mm / L12mm,4400129,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,443,265.8,,465.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,155.71,35.15,,124.568,percent of total billed charges,35.15% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,168.34,38,,134.672,percent of total billed charges,38% of total billed charges,141.54,31.95,,113.232,percent of total billed charges,31.95% of total billed charges,5436.94,7088,
LOCKING SCREW T10 FULL THREAD 3.5mm / L14mm,4400130,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,443,265.8,,465.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,155.71,35.15,,124.568,percent of total billed charges,35.15% of total billed charges,271.58,31.95,,217.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,168.34,38,,134.672,percent of total billed charges,38% of total billed charges,141.54,31.95,,113.232,percent of total billed charges,31.95% of total billed charges,5437.94,7089,
LOCKING SCREW T10 FULL THREAD 3.5mm / L16mm,4400131,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,545,327,,572.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,191.57,35.15,,153.256,percent of total billed charges,35.15% of total billed charges,273.17,31.95,,218.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,207.1,38,,165.68,percent of total billed charges,38% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,5438.94,7090,
LOCKING SCREW T10 FULL THREAD 3.5mm / L18mm,4400132,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,454,272.4,,476.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,159.58,35.15,,127.664,percent of total billed charges,35.15% of total billed charges,273.81,31.95,,219.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,172.52,38,,138.016,percent of total billed charges,38% of total billed charges,145.05,31.95,,116.04,percent of total billed charges,31.95% of total billed charges,5439.94,7091,
LOCKING SCREW T10 FULL THREAD 3.5mm / L20mm,4400133,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,274.77,31.95,,219.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5440.94,7092,
LOCKING SCREW T10 FULL THREAD 3.5mm / L22mm,4400134,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,280.52,31.95,,224.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5441.94,7093,
LOCKING SCREW T10 FULL THREAD 3.5mm / L24mm,4400135,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5442.94,7094,
LOCKING SCREW T10 FULL THREAD 3.5mm / L26mm,4400136,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5443.94,7095,
LOCKING SCREW T10 FULL THREAD 3.5mm / L28mm,4400137,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,285.95,31.95,,228.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5444.94,7096,
LOCKING SCREW T10 FULL THREAD 3.5mm / L30mm,4400138,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5445.94,7097,
LOCKING SCREW T10 FULL THREAD 3.5mm / L32mm,4400139,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5446.94,7098,
LOCKING SCREW T10 FULL THREAD 3.5mm / L34mm,4400140,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,360,216,,378,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,126.54,35.15,,101.232,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,136.8,38,,109.44,percent of total billed charges,38% of total billed charges,115.02,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,5447.94,7099,
LOCKING SCREW T10 FULL THREAD 3.5mm / L36mm,4400141,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5448.94,7100,
LOCKING SCREW T10 FULL THREAD 3.5mm / L38mm,4400142,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5449.94,7101,
LOCKING SCREW T10 FULL THREAD 3.5mm / L40mm,4400143,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,392,235.2,,411.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,137.79,35.15,,110.232,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,148.96,38,,119.168,percent of total billed charges,38% of total billed charges,125.24,31.95,,100.192,percent of total billed charges,31.95% of total billed charges,5450.94,7102,
LOCKING SCREW T10 FULL THREAD 3.5mm / L42mm,4400144,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5451.94,7103,
LOCKING SCREW T10 FULL THREAD 3.5mm / L44mm,4400145,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5452.94,7104,
LOCKING SCREW T10 FULL THREAD 3.5mm / L46mm,4400146,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5453.94,7105,
LOCKING SCREW T10 FULL THREAD 3.5mm / L48mm,4400147,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5454.94,7106,
LOCKING SCREW T10 FULL THREAD 3.5mm / L50mm,4400148,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5455.94,7107,
LOCKING SCREW T10 FULL THREAD 3.5mm / L55mm,4400149,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5456.94,7108,
LOCKING SCREW T10 FULL THREAD 3.5mm/L60mm,4400150,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5457.94,7109,
LOCKING SCREW T10 FULL THREAD 3.5mm / L65mm,4400151,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332,199.2,,348.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,93.36,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,5458.94,7110,
LOCKING SCREW T10 FULL THREAD 3.5mm / L70mm,4400152,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46.95,28.17,,49.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.5,35.15,,13.2,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.84,38,,14.272,percent of total billed charges,38% of total billed charges,15,31.95,,12,percent of total billed charges,31.95% of total billed charges,5459.94,7111,
BONE SCREW T10 FULL THREAD 3.5mm / L8mm,4400153,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,25.5,15.3,,26.78,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.96,35.15,,7.168,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.69,38,,7.752,percent of total billed charges,38% of total billed charges,8.15,31.95,,6.52,percent of total billed charges,31.95% of total billed charges,5460.94,7112,
BONE SCREW T10 FULL THREAD 3.5mm / L10mm,4400154,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,180,108,,189,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,50.616,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.4,38,,54.72,percent of total billed charges,38% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,5461.94,7113,
BONE SCREW T10 FULL THREAD 3.5mm / L12mm,4400155,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,331,198.6,,347.55,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.35,35.15,,93.08,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.78,38,,100.624,percent of total billed charges,38% of total billed charges,105.75,31.95,,84.6,percent of total billed charges,31.95% of total billed charges,5462.94,7114,
BONE SCREW T10 FULL THREAD 3.5mm / L14mm,4400156,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,271,162.6,,284.55,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,95.26,35.15,,76.208,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.98,38,,82.384,percent of total billed charges,38% of total billed charges,86.58,31.95,,69.264,percent of total billed charges,31.95% of total billed charges,5463.94,7115,
BONE SCREW T10 FULL THREAD 3.5mm / L16mm,4400157,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,330,198,,346.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116,35.15,,92.8,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,5464.94,7116,
BONE SCREW T10 FULL THREAD 3.5mm / L18mm,4400158,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,330,198,,346.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116,35.15,,92.8,percent of total billed charges,35.15% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,5465.94,7117,
BONE SCREW T10 FULL THREAD 3.5mm / L20mm,4400159,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,330,198,,346.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116,35.15,,92.8,percent of total billed charges,35.15% of total billed charges,303.84,31.95,,243.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,5466.94,7118,
BONE SCREW T10 FULL THREAD 3.5mm / L22mm,4400160,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,180,108,,189,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,50.616,percent of total billed charges,35.15% of total billed charges,311.19,31.95,,248.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.4,38,,54.72,percent of total billed charges,38% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,5467.94,7119,
BONE SCREW T10 FULL THREAD 3.5mm / L24mm,4400161,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,330,198,,346.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116,35.15,,92.8,percent of total billed charges,35.15% of total billed charges,311.51,31.95,,249.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,5468.94,7120,
BONE SCREW T10 FULL THREAD 3.5mm / L26mm,4400162,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,181,108.6,,190.05,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.62,35.15,,50.896,percent of total billed charges,35.15% of total billed charges,317.58,31.95,,254.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.78,38,,55.024,percent of total billed charges,38% of total billed charges,57.83,31.95,,46.264,percent of total billed charges,31.95% of total billed charges,5469.94,7121,
BONE SCREW T10 FULL THREAD 3.5mm / L28mm,4400163,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,330,198,,346.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116,35.15,,92.8,percent of total billed charges,35.15% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,5470.94,7122,
BONE SCREW T10 FULL THREAD 3.5mm / L30mm,4400164,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,330,198,,346.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116,35.15,,92.8,percent of total billed charges,35.15% of total billed charges,337.07,31.95,,269.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,5471.94,7123,
BONE SCREW T10 FULL THREAD 3.5mm / L32mm,4400165,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,270,162,,283.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,94.91,35.15,,75.928,percent of total billed charges,35.15% of total billed charges,365.51,31.95,,292.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.6,38,,82.08,percent of total billed charges,38% of total billed charges,86.27,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,5472.94,7124,
BONE SCREW T10 FULL THREAD 3.5mm / L34mm,4400166,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,330,198,,346.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116,35.15,,92.8,percent of total billed charges,35.15% of total billed charges,97.13,31.95,,77.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,125.4,38,,100.32,percent of total billed charges,38% of total billed charges,105.44,31.95,,84.352,percent of total billed charges,31.95% of total billed charges,5473.94,7125,
BONE SCREW T10 FULL THREAD 3.5mm / L36mm,4400167,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,180,108,,189,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,50.616,percent of total billed charges,35.15% of total billed charges,107.99,31.95,,86.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.4,38,,54.72,percent of total billed charges,38% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,5474.94,7126,
BONE SCREW T10 FULL THREAD 3.5mm / L38mm,4400168,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,270,162,,283.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,94.91,35.15,,75.928,percent of total billed charges,35.15% of total billed charges,195.85,31.95,,156.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.6,38,,82.08,percent of total billed charges,38% of total billed charges,86.27,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,5475.94,7127,
BONE SCREW T10 FULL THREAD 3.5mm / L40mm,4400169,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,181,108.6,,190.05,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.62,35.15,,50.896,percent of total billed charges,35.15% of total billed charges,227.16,31.95,,181.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.78,38,,55.024,percent of total billed charges,38% of total billed charges,57.83,31.95,,46.264,percent of total billed charges,31.95% of total billed charges,5476.94,7128,
BONE SCREW T10 FULL THREAD 3.5mm / L42mm,4400170,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55.5,33.3,,58.28,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.51,35.15,,15.608,percent of total billed charges,35.15% of total billed charges,36.17,31.95,,28.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.09,38,,16.872,percent of total billed charges,38% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,5477.94,7129,
BONE SCREW T10 FULL THREAD 3.5mm / L44mm,4400171,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,208,124.8,,218.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.11,35.15,,58.488,percent of total billed charges,35.15% of total billed charges,42.17,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.04,38,,63.232,percent of total billed charges,38% of total billed charges,66.46,31.95,,53.168,percent of total billed charges,31.95% of total billed charges,5478.94,7130,
BONE SCREW T10 FULL THREAD 3.5mm / L46mm,4400172,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,181,108.6,,190.05,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.62,35.15,,50.896,percent of total billed charges,35.15% of total billed charges,45.15,31.95,,36.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.78,38,,55.024,percent of total billed charges,38% of total billed charges,57.83,31.95,,46.264,percent of total billed charges,31.95% of total billed charges,5479.94,7131,
BONE SCREW T10 FULL THREAD 3.5mm / L48mm,4400173,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55.5,33.3,,58.28,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.51,35.15,,15.608,percent of total billed charges,35.15% of total billed charges,46.33,31.95,,37.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.09,38,,16.872,percent of total billed charges,38% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,5480.94,7132,
BONE SCREW T10 FULL THREAD 3.5mm / L50mm,4400174,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,440,264,,462,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,154.66,35.15,,123.728,percent of total billed charges,35.15% of total billed charges,85.31,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,167.2,38,,133.76,percent of total billed charges,38% of total billed charges,140.58,31.95,,112.464,percent of total billed charges,31.95% of total billed charges,5481.94,7133,
BONE SCREW T10 FULL THREAD 3.5mm / L55mm,4400175,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55.5,33.3,,58.28,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.51,35.15,,15.608,percent of total billed charges,35.15% of total billed charges,91.06,31.95,,72.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.09,38,,16.872,percent of total billed charges,38% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,5482.94,7134,
BONE SCREW T10 FULL THREAD 3.5mm / L60mm,4400176,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,180,108,,189,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,50.616,percent of total billed charges,35.15% of total billed charges,107.99,31.95,,86.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.4,38,,54.72,percent of total billed charges,38% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,5483.94,7135,
BONE SCREW T10 FULL THREAD 3.5mm / L65mm,4400177,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55.5,33.3,,58.28,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.51,35.15,,15.608,percent of total billed charges,35.15% of total billed charges,118.85,31.95,,95.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.09,38,,16.872,percent of total billed charges,38% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,5484.94,7136,
BONE SCREW T10 FULL THREAD 3.5mm / L70mm,4400178,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55.5,33.3,,58.28,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.51,35.15,,15.608,percent of total billed charges,35.15% of total billed charges,120.77,31.95,,96.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.09,38,,16.872,percent of total billed charges,38% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,5485.94,7137,
"OVERDRILL AO, DIA 3.5mm x 122mm",4400181,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,310,186,,325.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.97,35.15,,87.176,percent of total billed charges,35.15% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.8,38,,94.24,percent of total billed charges,38% of total billed charges,99.05,31.95,,79.24,percent of total billed charges,31.95% of total billed charges,5486.94,7138,
"OVERDRILL AO, DIA 2.4mm x 122mm",4400183,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,41.7,25.02,,43.79,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.66,35.15,,11.728,percent of total billed charges,35.15% of total billed charges,397.14,31.95,,317.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.85,38,,12.68,percent of total billed charges,38% of total billed charges,13.32,31.95,,10.656,percent of total billed charges,31.95% of total billed charges,5487.94,7139,
2MM K-WIRE WITH STOP - FOR T10 SCREW HEAD,4400184,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,335,201,,351.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,117.75,35.15,,94.2,percent of total billed charges,35.15% of total billed charges,397.78,31.95,,318.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.3,38,,101.84,percent of total billed charges,38% of total billed charges,107.03,31.95,,85.624,percent of total billed charges,31.95% of total billed charges,5488.94,7140,
SPEEDGUIDE DRILL AO DIA 2.0mm (L = 30mm),4400186,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,243,145.8,,255.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,85.41,35.15,,68.328,percent of total billed charges,35.15% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,92.34,38,,73.872,percent of total billed charges,38% of total billed charges,77.64,31.95,,62.112,percent of total billed charges,31.95% of total billed charges,5489.94,7141,
"SPEEDGUIDE DRILL AO, DIA 2.6mm (L = 30mm)",4400187,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,530,318,,556.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,186.3,35.15,,149.04,percent of total billed charges,35.15% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,201.4,38,,161.12,percent of total billed charges,38% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,5490.94,7142,
OVERDRILL AO DIA 2.7mm x 122mm,4400189,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,41.7,25.02,,43.79,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.66,35.15,,11.728,percent of total billed charges,35.15% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.85,38,,12.68,percent of total billed charges,38% of total billed charges,13.32,31.95,,10.656,percent of total billed charges,31.95% of total billed charges,5491.94,7143,
TAP AO FOR 3.5mm SCREWS,4400190,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,605,363,,635.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,212.66,35.15,,170.128,percent of total billed charges,35.15% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,229.9,38,,183.92,percent of total billed charges,38% of total billed charges,193.3,31.95,,154.64,percent of total billed charges,31.95% of total billed charges,5492.94,7144,
"TAP AO, FOR 2.7mm SCREWS",4400191,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,81.9,49.14,,86,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.79,35.15,,23.032,percent of total billed charges,35.15% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.12,38,,24.896,percent of total billed charges,38% of total billed charges,26.17,31.95,,20.936,percent of total billed charges,31.95% of total billed charges,5493.94,7145,
"TAP AO, FOR 2.4mm SCREWS",4400192,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,81.9,49.14,,86,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.79,35.15,,23.032,percent of total billed charges,35.15% of total billed charges,479.25,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,31.12,38,,24.896,percent of total billed charges,38% of total billed charges,26.17,31.95,,20.936,percent of total billed charges,31.95% of total billed charges,5494.94,7146,
DISTAL LATERAL FIBULA PLATE 3 HOLE,4400193,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1565,939,,1643.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,550.1,35.15,,440.08,percent of total billed charges,35.15% of total billed charges,479.25,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,594.7,38,,475.76,percent of total billed charges,38% of total billed charges,500.02,31.95,,400.016,percent of total billed charges,31.95% of total billed charges,5495.94,7147,
DISTAL LATERAL FIBULA PLATE 4 HOLE,4400194,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1500,900,,1575,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,527.25,35.15,,421.8,percent of total billed charges,35.15% of total billed charges,499.7,31.95,,399.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,570,38,,456,percent of total billed charges,38% of total billed charges,479.25,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,5496.94,7148,
DISTAL LATERAL FIBULA PLATE 5 HOLE,4400195,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1565,939,,1643.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,550.1,35.15,,440.08,percent of total billed charges,35.15% of total billed charges,511.2,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,594.7,38,,475.76,percent of total billed charges,38% of total billed charges,500.02,31.95,,400.016,percent of total billed charges,31.95% of total billed charges,5497.94,7149,
DISTAL LATERAL FIBULA PLATE 6 HOLE,4400196,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1220,732,,1281,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,428.83,35.15,,343.064,percent of total billed charges,35.15% of total billed charges,511.2,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,463.6,38,,370.88,percent of total billed charges,38% of total billed charges,389.79,31.95,,311.832,percent of total billed charges,31.95% of total billed charges,5498.94,7150,
DISTAL LATERAL FIBULA PLATE 7 HOLE,4400197,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1081,648.6,,1135.05,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,379.97,35.15,,303.976,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,410.78,38,,328.624,percent of total billed charges,38% of total billed charges,345.38,31.95,,276.304,percent of total billed charges,31.95% of total billed charges,5499.94,7151,
DISTAL LATERAL FIBULA PLATE 8 HOLE,4400198,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1325,795,,1391.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,465.74,35.15,,372.592,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,503.5,38,,402.8,percent of total billed charges,38% of total billed charges,423.34,31.95,,338.672,percent of total billed charges,31.95% of total billed charges,5500.94,7152,
DISTAL LATERAL FIBULA PLATE 9 HOLE,4400199,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,368.1,220.86,,386.51,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,129.39,35.15,,103.512,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,139.88,38,,111.904,percent of total billed charges,38% of total billed charges,117.61,31.95,,94.088,percent of total billed charges,31.95% of total billed charges,5501.94,7153,
4.0 X24MM TI CANNULATED SCREW,4400200,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,398,238.8,,417.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.9,35.15,,111.92,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,151.24,38,,120.992,percent of total billed charges,38% of total billed charges,127.16,31.95,,101.728,percent of total billed charges,31.95% of total billed charges,5502.94,7154,
4.0 X26MM TI CANNULATED SCREW,4400201,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5503.94,7155,
4.0 X28MM TI CANNULATED SCREW,4400202,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5504.94,7156,
4.0 X30MM TI CANNULATED SCREW,4400203,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5505.94,7157,
4.0 X32MM TI CANNULATED SCREW,4400204,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5506.94,7158,
4.0 X34MM TI CANNULATED SCREW,4400205,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5507.94,7159,
4.0 X36MM TI CANNULATED SCREW,4400206,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,5508.94,7160,
4.0 X38MM TI CANNULATED SCREW,4400207,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5509.94,7161,
4.0 X40MM TI CANNULATED SCREW,4400208,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,5510.94,7162,
4.0 X42MM TI CANNULATED SCREW,4400209,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5511.94,7163,
4.0 X44MM TI CANNULATED SCREW,4400210,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5512.94,7164,
4.0 X46MM TI CANNULATED SCREW,4400211,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5513.94,7165,
4.0 X48MM TI CANNULATED SCREW,4400212,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5514.94,7166,
4.0 X50MM TI CANNULATED SCREW,4400213,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5515.94,7167,
4.0 X55MM TI CANNULATED SCREW,4400214,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5516.94,7168,
4.0 X60MM TI CANNULATED SCREW,4400215,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5517.94,7169,
4.0 X65MM TI CANNULATED SCREW,4400216,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5518.94,7170,
4.0 X70MM TI CANNULATED SCREW,4400217,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,90.6,54.36,,95.13,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.85,35.15,,25.48,percent of total billed charges,35.15% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.43,38,,27.544,percent of total billed charges,38% of total billed charges,28.95,31.95,,23.16,percent of total billed charges,31.95% of total billed charges,5519.94,7171,
Ti ASNIS III WASHER 4.0mm,4400218,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,100,60,,105,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.15,35.15,,28.12,percent of total billed charges,35.15% of total billed charges,531.01,31.95,,424.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38,38,,30.4,percent of total billed charges,38% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,5520.94,7172,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM,4400219,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,690,414,,724.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,242.54,35.15,,194.032,percent of total billed charges,35.15% of total billed charges,543.15,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,262.2,38,,209.76,percent of total billed charges,38% of total billed charges,220.46,31.95,,176.368,percent of total billed charges,31.95% of total billed charges,5521.94,7173,
ONE-THIRD TUBULAR PLATE 3 HOLE / L35MM,4400220,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,141.9,85.14,,149,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.88,35.15,,39.904,percent of total billed charges,35.15% of total billed charges,543.15,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.92,38,,43.136,percent of total billed charges,38% of total billed charges,45.34,31.95,,36.272,percent of total billed charges,31.95% of total billed charges,5522.94,7174,
ONE-THIRD TUBULAR PLATE 4 HOLE / L47MM,4400221,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,740,444,,777,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,260.11,35.15,,208.088,percent of total billed charges,35.15% of total billed charges,555.93,31.95,,444.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,281.2,38,,224.96,percent of total billed charges,38% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,5523.94,7175,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM,4400222,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,560,336,,588,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,196.84,35.15,,157.472,percent of total billed charges,35.15% of total billed charges,555.93,31.95,,444.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,212.8,38,,170.24,percent of total billed charges,38% of total billed charges,178.92,31.95,,143.136,percent of total billed charges,31.95% of total billed charges,5524.94,7176,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM,4400223,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,560,336,,588,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,196.84,35.15,,157.472,percent of total billed charges,35.15% of total billed charges,557.53,31.95,,446.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,212.8,38,,170.24,percent of total billed charges,38% of total billed charges,178.92,31.95,,143.136,percent of total billed charges,31.95% of total billed charges,5525.94,7177,
ONE-THIRD TUBULAR PLATE 7 HOLE / L83MM,4400224,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,560,336,,588,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,196.84,35.15,,157.472,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,212.8,38,,170.24,percent of total billed charges,38% of total billed charges,178.92,31.95,,143.136,percent of total billed charges,31.95% of total billed charges,5526.94,7178,
ONE-THIRD TUBULAR PLATE 8 HOLE / L95MM,4400225,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,747,448.2,,784.35,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,262.57,35.15,,210.056,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,283.86,38,,227.088,percent of total billed charges,38% of total billed charges,238.67,31.95,,190.936,percent of total billed charges,31.95% of total billed charges,5527.94,7179,
ONE-THIRD TUBULAR PLATE 9 HOLE / L107MM,4400226,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,204.9,122.94,,215.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,72.02,35.15,,57.616,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,77.86,38,,62.288,percent of total billed charges,38% of total billed charges,65.47,31.95,,52.376,percent of total billed charges,31.95% of total billed charges,5528.94,7180,
ONE-THIRD TUBULAR PLATE 10 HOLE / L119MM,4400227,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,204.9,122.94,,215.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,72.02,35.15,,57.616,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,77.86,38,,62.288,percent of total billed charges,38% of total billed charges,65.47,31.95,,52.376,percent of total billed charges,31.95% of total billed charges,5529.94,7181,
ONE-THIRD TUBULAR PLATE 12 HOLE / L143MM,4400228,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,5530.94,7182,
ONE-THIRD TUBULAR PLATE 14 HOLE / L167MM,4400229,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,283.5,170.1,,297.68,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,99.65,35.15,,79.72,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,107.73,38,,86.184,percent of total billed charges,38% of total billed charges,90.58,31.95,,72.464,percent of total billed charges,31.95% of total billed charges,5531.94,7183,
ONE-THIRD TUBULAR PLATE 16 HOLE / L191MM,4400230,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,283.5,170.1,,297.68,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,99.65,35.15,,79.72,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,107.73,38,,86.184,percent of total billed charges,38% of total billed charges,90.58,31.95,,72.464,percent of total billed charges,31.95% of total billed charges,5532.94,7184,
"VARIAX COMPRESSION PLATE, NARROW, STRAIGHT, 4 HOLES",4400231,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,600,360,,630,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,210.9,35.15,,168.72,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,182.4,percent of total billed charges,38% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,5533.94,7185,
"VARIAX COMPRESSION PLATE, NARROW, STRAIGHT, 5 HOLES",4400232,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,546,327.6,,573.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,191.92,35.15,,153.536,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,207.48,38,,165.984,percent of total billed charges,38% of total billed charges,174.45,31.95,,139.56,percent of total billed charges,31.95% of total billed charges,5534.94,7186,
"VARIAX COMPRESSIONPLATE, NARROW, STRAIGHT, 6 HOLES",4400233,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,857,514.2,,899.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,301.24,35.15,,240.992,percent of total billed charges,35.15% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,325.66,38,,260.528,percent of total billed charges,38% of total billed charges,273.81,31.95,,219.048,percent of total billed charges,31.95% of total billed charges,5535.94,7187,
VARIAX COMPRESSION PLATE 7 HOLE/L90 WITH 2 LOCKING HOLES,4400234,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1090,654,,1144.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,383.14,35.15,,306.512,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,414.2,38,,331.36,percent of total billed charges,38% of total billed charges,348.26,31.95,,278.608,percent of total billed charges,31.95% of total billed charges,5536.94,7188,
"VARIAX COMPRESSION PLATE, NARROW, STRAIGHT, 8 HOLES",4400235,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1169,701.4,,1227.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,410.9,35.15,,328.72,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,444.22,38,,355.376,percent of total billed charges,38% of total billed charges,373.5,31.95,,298.8,percent of total billed charges,31.95% of total billed charges,5537.94,7189,
"VARIAX COMPRESSION PLATE, NARROW, STRAIGHT, 9 HOLES",4400236,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5538.94,7190,
VARIAX COMPRESSION PLATE NARROW STRAIGHT 10 HOLES,4400237,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1170,702,,1228.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,411.26,35.15,,329.008,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,444.6,38,,355.68,percent of total billed charges,38% of total billed charges,373.82,31.95,,299.056,percent of total billed charges,31.95% of total billed charges,5539.94,7191,
VARIAX COMPRESSION PLATE 7 HOLE/L90mm WITH 4 LOCKING HOLES,4400238,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,797,478.2,,836.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,280.15,35.15,,224.12,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,242.288,percent of total billed charges,38% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5540.94,7192,
VARIAX COMPRESSION PLATE 7 HOLE/L91mm WITH 4 LOCKING HOLES,4400239,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,797,478.2,,836.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,280.15,35.15,,224.12,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,242.288,percent of total billed charges,38% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5541.94,7193,
"VARIAX COMPRESSION PLATE, BROAD, STRAIGHT, 4 HOLES",4400240,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,115.26,69.156,,121.02,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.51,35.15,,32.408,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.8,38,,35.04,percent of total billed charges,38% of total billed charges,36.83,31.95,,29.464,percent of total billed charges,31.95% of total billed charges,5542.94,7194,
"VARIAX COMPRESSION PLATE, BROAD, STRAIGHT, 5 HOLES",4400241,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,797,478.2,,836.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,280.15,35.15,,224.12,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,242.288,percent of total billed charges,38% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5543.94,7195,
VARIAX COMPRESSION PLATE BROAD STRAIGHT 6 HOLES,4400243,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,797,478.2,,836.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,280.15,35.15,,224.12,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,242.288,percent of total billed charges,38% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5544.94,7196,
VARIAX COMPRESSION PLATE 7 HOLE/L91mm WITH 2 LOCKING HOLES,4400244,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,797,478.2,,836.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,280.15,35.15,,224.12,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,302.86,38,,242.288,percent of total billed charges,38% of total billed charges,254.64,31.95,,203.712,percent of total billed charges,31.95% of total billed charges,5545.94,7197,
"VARIAX COMPRESSION PLATE, BROAD, STRAIGHT, 8 HOLES",4400245,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,271.56,162.936,,285.14,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,95.45,35.15,,76.36,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,103.19,38,,82.552,percent of total billed charges,38% of total billed charges,86.76,31.95,,69.408,percent of total billed charges,31.95% of total billed charges,5546.94,7198,
"VARIAX COMPRESSION PLATE, BROAD, CURVED, 9 HOLES",4400246,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,271.56,162.936,,285.14,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,95.45,35.15,,76.36,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,103.19,38,,82.552,percent of total billed charges,38% of total billed charges,86.76,31.95,,69.408,percent of total billed charges,31.95% of total billed charges,5547.94,7199,
"VARIAX COMPRESSION PLATE, BROAD, CURVED, 10 HOLES",4400247,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1169,701.4,,1227.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,410.9,35.15,,328.72,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,444.22,38,,355.376,percent of total billed charges,38% of total billed charges,373.5,31.95,,298.8,percent of total billed charges,31.95% of total billed charges,5548.94,7200,
"VARIAX COMPRESSION PLATE, BROAD, CURVED, 11 HOLES",4400248,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332.46,199.476,,349.08,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.86,35.15,,93.488,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.33,38,,101.064,percent of total billed charges,38% of total billed charges,106.22,31.95,,84.976,percent of total billed charges,31.95% of total billed charges,5549.94,7201,
"VARIAX COMPRESSION PLATE, BROAD, CURVED, 12 HOLES",4400249,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332.46,199.476,,349.08,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.86,35.15,,93.488,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.33,38,,101.064,percent of total billed charges,38% of total billed charges,106.22,31.95,,84.976,percent of total billed charges,31.95% of total billed charges,5550.94,7202,
"VARIAX COMPRESSION PLATE, BROAD, CURVED, 14 HOLES",4400250,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,332.46,199.476,,349.08,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.86,35.15,,93.488,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,126.33,38,,101.064,percent of total billed charges,38% of total billed charges,106.22,31.95,,84.976,percent of total billed charges,31.95% of total billed charges,5551.94,7203,
CANN 4.0mm TWIST DRILL W/ AO,4400251,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,170.85,102.51,,179.39,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,60.05,35.15,,48.04,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.92,38,,51.936,percent of total billed charges,38% of total billed charges,54.59,31.95,,43.672,percent of total billed charges,31.95% of total billed charges,5552.94,7204,
CANN 2.7mm TWIST DRILL W/ AO F,4400252,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,817,490.2,,857.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,287.18,35.15,,229.744,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,310.46,38,,248.368,percent of total billed charges,38% of total billed charges,261.03,31.95,,208.824,percent of total billed charges,31.95% of total billed charges,5553.94,7205,
ASNIS III 1.4X150mm GUIDE WIRE,4400253,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,41.7,25.02,,43.79,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.66,35.15,,11.728,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.85,38,,12.68,percent of total billed charges,38% of total billed charges,13.32,31.95,,10.656,percent of total billed charges,31.95% of total billed charges,5554.94,7206,
0.045 IN. (1.143mm) K-WIRE W/LENGTH MARKINGS,4400254,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,5.04,3.024,,5.29,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1.77,35.15,,1.416,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1.92,38,,1.536,percent of total billed charges,38% of total billed charges,1.61,31.95,,1.288,percent of total billed charges,31.95% of total billed charges,5555.94,7207,
DORSAL SMARTLOCK  PLATE STANDARD RIGHT,4400255,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,169.59,101.754,,178.07,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.61,35.15,,47.688,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.44,38,,51.552,percent of total billed charges,38% of total billed charges,54.18,31.95,,43.344,percent of total billed charges,31.95% of total billed charges,5556.94,7208,
DORSAL SMARTLOCK  PLATE STANDARD LEFT,4400256,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,169.59,101.754,,178.07,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.61,35.15,,47.688,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.44,38,,51.552,percent of total billed charges,38% of total billed charges,54.18,31.95,,43.344,percent of total billed charges,31.95% of total billed charges,5557.94,7209,
DORSAL SMARTLOCK  PLATE WIDE RIGHT,4400257,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,169.59,101.754,,178.07,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.61,35.15,,47.688,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.44,38,,51.552,percent of total billed charges,38% of total billed charges,54.18,31.95,,43.344,percent of total billed charges,31.95% of total billed charges,5558.94,7210,
DORSAL SMARTLOCK PLATE WIDE LEFT,4400258,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,169.59,101.754,,178.07,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.61,35.15,,47.688,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,64.44,38,,51.552,percent of total billed charges,38% of total billed charges,54.18,31.95,,43.344,percent of total billed charges,31.95% of total billed charges,5559.94,7211,
DORSAL SMARTLOCK DR PLATE STANDARD RIGHT X LONG,4400259,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,198.15,118.89,,208.06,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.65,35.15,,55.72,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,75.3,38,,60.24,percent of total billed charges,38% of total billed charges,63.31,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,5560.94,7212,
DORSAL SMARTLOCK DR PLATE STANDARD LEFT X LONG,4400260,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,198.15,118.89,,208.06,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.65,35.15,,55.72,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,75.3,38,,60.24,percent of total billed charges,38% of total billed charges,63.31,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,5561.94,7213,
DORSAL SMARTLOCK DR PLATE WIDE RIGHT X LONG,4400261,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,198.15,118.89,,208.06,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.65,35.15,,55.72,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,75.3,38,,60.24,percent of total billed charges,38% of total billed charges,63.31,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,5562.94,7214,
DORSAL SMARTLOCK DR PLATE WIDE LEFT X LONG,4400262,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,198.15,118.89,,208.06,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.65,35.15,,55.72,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,75.3,38,,60.24,percent of total billed charges,38% of total billed charges,63.31,31.95,,50.648,percent of total billed charges,31.95% of total billed charges,5563.94,7215,
VOLAR SMARTLOCK DR PLATE NARROW LEFT,4400263,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1670,1002,,1753.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,587.01,35.15,,469.608,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,634.6,38,,507.68,percent of total billed charges,38% of total billed charges,533.57,31.95,,426.856,percent of total billed charges,31.95% of total billed charges,5564.94,7216,
VOLAR SMARTLOCK DR PLATE  NARROW  LEFT  LONG,4400264,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,194.31,116.586,,204.03,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.3,35.15,,54.64,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.84,38,,59.072,percent of total billed charges,38% of total billed charges,62.08,31.95,,49.664,percent of total billed charges,31.95% of total billed charges,5565.94,7217,
VOLAR SMARTLOCK DR PLATE STANDARD  LEFT,4400265,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1670,1002,,1753.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,587.01,35.15,,469.608,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,634.6,38,,507.68,percent of total billed charges,38% of total billed charges,533.57,31.95,,426.856,percent of total billed charges,31.95% of total billed charges,5566.94,7218,
VOLAR SMARTLOCK DR PLATE  STANDARD  LEFT  LONG,4400266,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,194.31,116.586,,204.03,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.3,35.15,,54.64,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.84,38,,59.072,percent of total billed charges,38% of total billed charges,62.08,31.95,,49.664,percent of total billed charges,31.95% of total billed charges,5567.94,7219,
VOLAR SMARTLOCK DR PLATE NARROW RIGHT,4400267,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5568.94,7220,
VOLAR SMARTLOCK DR PLATE  NARROW  RIGHT  LONG,4400268,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,194.31,116.586,,204.03,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.3,35.15,,54.64,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.84,38,,59.072,percent of total billed charges,38% of total billed charges,62.08,31.95,,49.664,percent of total billed charges,31.95% of total billed charges,5569.94,7221,
VOLAR SMARTLOCK DR PLATE  STANDARD  RIGHT,4400269,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,166.11,99.666,,174.42,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,58.39,35.15,,46.712,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.12,38,,50.496,percent of total billed charges,38% of total billed charges,53.07,31.95,,42.456,percent of total billed charges,31.95% of total billed charges,5570.94,7222,
VOLAR SMARTLOCK DR PLATE  STANDARD  RIGHT  LONG,4400270,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,194.31,116.586,,204.03,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.3,35.15,,54.64,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,73.84,38,,59.072,percent of total billed charges,38% of total billed charges,62.08,31.95,,49.664,percent of total billed charges,31.95% of total billed charges,5571.94,7223,
RADIAL COLUMN SMARTLOCK PLATE SHORT,4400271,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,119.55,71.73,,125.53,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.02,35.15,,33.616,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.43,38,,36.344,percent of total billed charges,38% of total billed charges,38.2,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,5572.94,7224,
RADIAL COLUMN SMARTLOCK PLATE LONG,4400272,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,119.55,71.73,,125.53,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.02,35.15,,33.616,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.43,38,,36.344,percent of total billed charges,38% of total billed charges,38.2,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,5573.94,7225,
ULNAR COLUMN SMARTLOCK PLATE SHORT RIGHT,4400273,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1245,747,,1307.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,437.62,35.15,,350.096,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,473.1,38,,378.48,percent of total billed charges,38% of total billed charges,397.78,31.95,,318.224,percent of total billed charges,31.95% of total billed charges,5574.94,7226,
ULNAR COLUMN SMARTLOCK PLATE SHORT LEFT,4400274,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,119.55,71.73,,125.53,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.02,35.15,,33.616,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.43,38,,36.344,percent of total billed charges,38% of total billed charges,38.2,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,5575.94,7227,
ULNAR COLUMN SMARTLOCK PLATE LONG RIGHT,4400275,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,119.55,71.73,,125.53,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.02,35.15,,33.616,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.43,38,,36.344,percent of total billed charges,38% of total billed charges,38.2,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,5576.94,7228,
ULNAR COLUMN SMARTLOCK PLATE LONG LEFT,4400276,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,119.55,71.73,,125.53,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.02,35.15,,33.616,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.43,38,,36.344,percent of total billed charges,38% of total billed charges,38.2,31.95,,30.56,percent of total billed charges,31.95% of total billed charges,5577.94,7229,
VOLAR DR PLATE NARROW  LEFT 8 HOLES  EXTRASHORT,4400277,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1788,1072.8,,1877.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,628.48,35.15,,502.784,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,679.44,38,,543.552,percent of total billed charges,38% of total billed charges,571.27,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,5578.94,7230,
VOLAR DR PLATE NARROW RIGHT 8 HOLES EXTRASHORT,4400278,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1788,1072.8,,1877.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,628.48,35.15,,502.784,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,679.44,38,,543.552,percent of total billed charges,38% of total billed charges,571.27,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,5579.94,7231,
VOLAR DR PLATE INTERMEDIATE  LEFT 10 HOLES  EXTRASHORT,4400279,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1428,856.8,,1499.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,501.94,35.15,,401.552,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,542.64,38,,434.112,percent of total billed charges,38% of total billed charges,456.25,31.95,,365,percent of total billed charges,31.95% of total billed charges,5580.94,7232,
VOLAR DR PLATE INTERMEDIATE  LEFT 11 HOLES  SHORT,4400280,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1788,1072.8,,1877.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,628.48,35.15,,502.784,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,679.44,38,,543.552,percent of total billed charges,38% of total billed charges,571.27,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,5581.94,7233,
VOLAR DR PLATE INTERMEDIATE  LEFT 14-HOLES  LONG,4400281,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2059,1235.4,,2161.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,723.74,35.15,,578.992,percent of total billed charges,35.15% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,782.42,38,,625.936,percent of total billed charges,38% of total billed charges,657.85,31.95,,526.28,percent of total billed charges,31.95% of total billed charges,5582.94,7234,
VOLAR DR PLATE INTERMEDIATE RIGHT 10 HOLES EXTRASHORT,4400282,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1788,1072.8,,1877.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,628.48,35.15,,502.784,percent of total billed charges,35.15% of total billed charges,3245.48,31.95,,2596.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,679.44,38,,543.552,percent of total billed charges,38% of total billed charges,571.27,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,5583.94,7235,
VOLAR DR PLATE INTERMEDIATE RIGHT 11 HOLES SHORT,4400283,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1788,1072.8,,1877.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,628.48,35.15,,502.784,percent of total billed charges,35.15% of total billed charges,648.59,31.95,,518.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,679.44,38,,543.552,percent of total billed charges,38% of total billed charges,571.27,31.95,,457.016,percent of total billed charges,31.95% of total billed charges,5584.94,7236,
VOLAR DR PLATE INTERMEDIATE RIGHT 14-HOLES LONG,4400284,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,648.59,31.95,,518.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5585.94,7237,
VOLAR DR PLATE STANDARD  LEFT 10 HOLES  EXTRASHORT,4400285,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,178.47,107.082,,187.39,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.73,35.15,,50.184,percent of total billed charges,35.15% of total billed charges,669.35,31.95,,535.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,67.82,38,,54.256,percent of total billed charges,38% of total billed charges,57.02,31.95,,45.616,percent of total billed charges,31.95% of total billed charges,5586.94,7238,
VOLAR DR PLATE STANDARD  RIGHT 10 HOLES  EXTRASHORT,4400286,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,178.47,107.082,,187.39,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.73,35.15,,50.184,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,67.82,38,,54.256,percent of total billed charges,38% of total billed charges,57.02,31.95,,45.616,percent of total billed charges,31.95% of total billed charges,5587.94,7239,
K-WIRE W/ 17mm STOP,4400287,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,85,51,,89.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,29.88,35.15,,23.904,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,5588.94,7240,
K-WIRE 3.2X450mm (STERILE),4400288,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,472,283.2,,495.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,165.91,35.15,,132.728,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,179.36,38,,143.488,percent of total billed charges,38% of total billed charges,150.8,31.95,,120.64,percent of total billed charges,31.95% of total billed charges,5589.94,7241,
GAMMA3 CLOSED TUBE CLIP,4400289,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,5590.94,7242,
DRILL 4.2X300mm AO SMALL STERILE,4400290,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,498,298.8,,522.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.05,35.15,,140.04,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,189.24,38,,151.392,percent of total billed charges,38% of total billed charges,159.11,31.95,,127.288,percent of total billed charges,31.95% of total billed charges,5591.94,7243,
DRILL 4.2X180mm AO SMALL STERILE,4400291,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,490,294,,514.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,172.24,35.15,,137.792,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,186.2,38,,148.96,percent of total billed charges,38% of total billed charges,156.56,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,5592.94,7244,
Ti SET SCREW 8X17.5mm,4400292,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42,25.2,,44.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.76,35.15,,11.808,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,12.768,percent of total billed charges,38% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,5593.94,7245,
Ti END CAP STANDARD 0mm,4400293,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42,25.2,,44.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.76,35.15,,11.808,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,12.768,percent of total billed charges,38% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,5594.94,7246,
Ti END CAP 5mm +5,4400294,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,42,25.2,,44.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.76,35.15,,11.808,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.96,38,,12.768,percent of total billed charges,38% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,5595.94,7247,
Ti LAG SCREW 10.5X75mm,4400295,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,855,513,,897.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,300.53,35.15,,240.424,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,324.9,38,,259.92,percent of total billed charges,38% of total billed charges,273.17,31.95,,218.536,percent of total billed charges,31.95% of total billed charges,5596.94,7248,
Ti LAG SCREW 10.5X80mm,4400296,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,850,510,,892.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,298.78,35.15,,239.024,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,323,38,,258.4,percent of total billed charges,38% of total billed charges,271.58,31.95,,217.264,percent of total billed charges,31.95% of total billed charges,5597.94,7249,
Ti LAG SCREW 10.5X85mm,4400297,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1000,600,,1050,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,351.5,35.15,,281.2,percent of total billed charges,35.15% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,304,percent of total billed charges,38% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,5598.94,7250,
Ti LAG SCREW 10.5X90mm,4400298,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1000,600,,1050,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,351.5,35.15,,281.2,percent of total billed charges,35.15% of total billed charges,766.8,31.95,,613.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,304,percent of total billed charges,38% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,5599.94,7251,
Ti LAG SCREW 10.5X95mm,4400299,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1395,837,,1464.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,490.34,35.15,,392.272,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,530.1,38,,424.08,percent of total billed charges,38% of total billed charges,445.7,31.95,,356.56,percent of total billed charges,31.95% of total billed charges,5600.94,7252,
Ti LAG SCREW 10.5X100mm,4400300,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1139,683.4,,1195.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,400.36,35.15,,320.288,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,432.82,38,,346.256,percent of total billed charges,38% of total billed charges,363.91,31.95,,291.128,percent of total billed charges,31.95% of total billed charges,5601.94,7253,
Ti LAG SCREW 10.5X105mm,4400301,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,860,516,,903,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,302.29,35.15,,241.832,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,326.8,38,,261.44,percent of total billed charges,38% of total billed charges,274.77,31.95,,219.816,percent of total billed charges,31.95% of total billed charges,5602.94,7254,
Ti LAG SCREW 10.5X110mm,4400302,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,117.24,70.344,,123.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,41.21,35.15,,32.968,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.55,38,,35.64,percent of total billed charges,38% of total billed charges,37.46,31.95,,29.968,percent of total billed charges,31.95% of total billed charges,5603.94,7255,
Ti LAG SCREW 10.5X115mm,4400303,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,117.24,70.344,,123.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,41.21,35.15,,32.968,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.55,38,,35.64,percent of total billed charges,38% of total billed charges,37.46,31.95,,29.968,percent of total billed charges,31.95% of total billed charges,5604.94,7256,
Ti LAG SCREW 10.5X120mm,4400304,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,117.24,70.344,,123.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,41.21,35.15,,32.968,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.55,38,,35.64,percent of total billed charges,38% of total billed charges,37.46,31.95,,29.968,percent of total billed charges,31.95% of total billed charges,5605.94,7257,
GAMMA 3 S NAIL RIGHT 10x320mm x 125,4400305,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,557.25,334.35,,585.11,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.87,35.15,,156.696,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,211.76,38,,169.408,percent of total billed charges,38% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,5606.94,7258,
GAMMA 3 S NAIL RIGHT 10x340mm x 125,4400306,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,557.25,334.35,,585.11,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.87,35.15,,156.696,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,211.76,38,,169.408,percent of total billed charges,38% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,5607.94,7259,
GAMMA 3 S NAIL RIGHT 10x360mm x 125,4400307,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,5815,3489,,6105.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2043.97,35.15,,1635.176,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2209.7,38,,1767.76,percent of total billed charges,38% of total billed charges,1857.89,31.95,,1486.312,percent of total billed charges,31.95% of total billed charges,5608.94,7260,
GAMMA 3 S NAIL RIGHT 10x380mm x 125,4400308,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3595,2157,,3774.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1263.64,35.15,,1010.912,percent of total billed charges,35.15% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1366.1,38,,1092.88,percent of total billed charges,38% of total billed charges,1148.6,31.95,,918.88,percent of total billed charges,31.95% of total billed charges,5609.94,7261,
GAMMA 3 S NAIL RIGHT 10x400mm x 125,4400309,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3595,2157,,3774.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1263.64,35.15,,1010.912,percent of total billed charges,35.15% of total billed charges,830.06,31.95,,664.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1366.1,38,,1092.88,percent of total billed charges,38% of total billed charges,1148.6,31.95,,918.88,percent of total billed charges,31.95% of total billed charges,5610.94,7262,
GAMMA 3 S NAIL LEFT 10x320mm x 125,4400311,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,557.25,334.35,,585.11,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.87,35.15,,156.696,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,211.76,38,,169.408,percent of total billed charges,38% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,5611.94,7263,
GAMMA 3 S NAIL LEFT 10x340mm x 125,4400312,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3617,2170.2,,3797.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1271.38,35.15,,1017.104,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1374.46,38,,1099.568,percent of total billed charges,38% of total billed charges,1155.63,31.95,,924.504,percent of total billed charges,31.95% of total billed charges,5612.94,7264,
GAMMA 3 S NAIL LEFT 10x360mm x 125,4400313,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5613.94,7265,
GAMMA 3 S NAIL LEFT 10x380mm x 125,4400314,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,557.25,334.35,,585.11,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.87,35.15,,156.696,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,211.76,38,,169.408,percent of total billed charges,38% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,5614.94,7266,
GAMMA 3 S NAIL LEFT 10x400mm x 125,4400315,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5615.94,7267,
GAMMA 3 S NAIL LEFT 10x420mm x 125,4400316,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,557.25,334.35,,585.11,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,195.87,35.15,,156.696,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,211.76,38,,169.408,percent of total billed charges,38% of total billed charges,178.04,31.95,,142.432,percent of total billed charges,31.95% of total billed charges,5616.94,7268,
T2 F/T LOCKING SCREW 5mmX25mm,4400317,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,38.88,23.328,,40.82,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.67,35.15,,10.936,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.77,38,,11.816,percent of total billed charges,38% of total billed charges,12.42,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,5617.94,7269,
T2 F/T LOCKING SCREW 5mmX27.5mm,4400318,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,5618.94,7270,
T2 F/T LOCKING SCREW 5mmX30mm,4400319,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,5619.94,7271,
T2 F/T LOCKING SCREW 5mmX32.5mm,4400320,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,38.88,23.328,,40.82,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.67,35.15,,10.936,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.77,38,,11.816,percent of total billed charges,38% of total billed charges,12.42,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,5620.94,7272,
T2 F/T LOCKING SCREW 5mmX35mm,4400321,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,470,282,,493.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,165.21,35.15,,132.168,percent of total billed charges,35.15% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,178.6,38,,142.88,percent of total billed charges,38% of total billed charges,150.17,31.95,,120.136,percent of total billed charges,31.95% of total billed charges,5621.94,7273,
T2 F/T LOCKING SCREW 5mmX37.5mm,4400322,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,864.25,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,5622.94,7274,
T2 F/T LOCKING SCREW 5mmX40mm,4400323,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,475,285,,498.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,166.96,35.15,,133.568,percent of total billed charges,35.15% of total billed charges,864.25,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,180.5,38,,144.4,percent of total billed charges,38% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,5623.94,7275,
T2 F/T LOCKING SCREW 5mmX42.5mm,4400324,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,463,277.8,,486.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,162.74,35.15,,130.192,percent of total billed charges,35.15% of total billed charges,864.25,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175.94,38,,140.752,percent of total billed charges,38% of total billed charges,147.93,31.95,,118.344,percent of total billed charges,31.95% of total billed charges,5624.94,7276,
T2 F/T LOCKING SCREW 5mmX45mm,4400325,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,400,240,,420,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,112.48,percent of total billed charges,35.15% of total billed charges,897.8,31.95,,718.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,152,38,,121.6,percent of total billed charges,38% of total billed charges,127.8,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,5625.94,7277,
T2 F/T LOCKING SCREW 5mmX47.5mm,4400326,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,926.55,31.95,,741.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,5626.94,7278,
T2 F/T LOCKING SCREW 5mmX50mm,4400327,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,475,285,,498.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,166.96,35.15,,133.568,percent of total billed charges,35.15% of total billed charges,958.5,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,180.5,38,,144.4,percent of total billed charges,38% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,5627.94,7279,
T2 F/T LOCKING SCREW 5mmX52.5mm,4400328,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,38.88,23.328,,40.82,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.67,35.15,,10.936,percent of total billed charges,35.15% of total billed charges,1022.4,31.95,,817.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.77,38,,11.816,percent of total billed charges,38% of total billed charges,12.42,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,5628.94,7280,
T2 F/T LOCKING SCREW 5mmX55mm,4400329,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,38.88,23.328,,40.82,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.67,35.15,,10.936,percent of total billed charges,35.15% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.77,38,,11.816,percent of total billed charges,38% of total billed charges,12.42,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,5629.94,7281,
T2 F/T LOCKING SCREW 5mmX57.5mm,4400330,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,38.88,23.328,,40.82,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.67,35.15,,10.936,percent of total billed charges,35.15% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.77,38,,11.816,percent of total billed charges,38% of total billed charges,12.42,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,5630.94,7282,
T2 F/T LOCKING SCREW 5mmX60mm,4400331,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,475,285,,498.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,166.96,35.15,,133.568,percent of total billed charges,35.15% of total billed charges,1062.34,31.95,,849.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,180.5,38,,144.4,percent of total billed charges,38% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,5631.94,7283,
T2 F/T LOCKING SCREW 5mmX65mm,4400332,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,38.88,23.328,,40.82,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.67,35.15,,10.936,percent of total billed charges,35.15% of total billed charges,1118.25,31.95,,894.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.77,38,,11.816,percent of total billed charges,38% of total billed charges,12.42,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,5632.94,7284,
ANTI FOG CLEANER (UC CLEARLY),4400333,CDM,272,RC,A4649,HCPCS,OUTPATIENT,,,38.88,23.328,,33.05,85,,26.44,Percent of total billed charges,85% of total billed charges,19.44,50,,15.552,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,19.44,50,,15.552,percent of total billed charges,50% of total billed charges,13.67,35.15,,10.936,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.77,38,,11.816,percent of total billed charges,38% of total billed charges,12.42,31.95,,9.936,percent of total billed charges,31.95% of total billed charges,5633.94,7285,
GAMMA GUIDE PIN 4X400mm STERILE,4400334,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,27.81,16.686,,29.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,9.78,35.15,,7.824,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,10.57,38,,8.456,percent of total billed charges,38% of total billed charges,8.89,31.95,,7.112,percent of total billed charges,31.95% of total billed charges,5634.94,7286,
DRILL 4.2X230mm AO SMALL STERILE,4400335,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,40.68,24.408,,42.71,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.3,35.15,,11.44,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.46,38,,12.368,percent of total billed charges,38% of total billed charges,13,31.95,,10.4,percent of total billed charges,31.95% of total billed charges,5635.94,7287,
Ti TROCHANTERIC NAIL KIT 11X180mm X 125,4400336,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2256,1353.6,,2368.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,792.98,35.15,,634.384,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,857.28,38,,685.824,percent of total billed charges,38% of total billed charges,720.79,31.95,,576.632,percent of total billed charges,31.95% of total billed charges,5636.94,7288,
Ti TROCHANTERIC NAIL KIT 11X180mm X 130,4400337,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2255,1353,,2367.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,792.63,35.15,,634.104,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,856.9,38,,685.52,percent of total billed charges,38% of total billed charges,720.47,31.95,,576.376,percent of total billed charges,31.95% of total billed charges,5637.94,7289,
6.5 X 40MM TI CANNULATED SCREW,4400338,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5638.94,7290,
6.5 X 45MM TI CANNULATED SCREW,4400339,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5639.94,7291,
6.5 X 50MM TI CANNULATED SCREW,4400340,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,455,273,,477.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,159.93,35.15,,127.944,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,172.9,38,,138.32,percent of total billed charges,38% of total billed charges,145.37,31.95,,116.296,percent of total billed charges,31.95% of total billed charges,5640.94,7292,
6.5 X55MM TI CANNULATED SCREW,4400355,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5641.94,7293,
6.5 X60MM TI CANNULATED SCREW,4400356,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5642.94,7294,
6.5 X65MM TI CANNULATED SCREW,4400357,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5643.94,7295,
6.5 X70MM TI CANNULATED SCREW,4400358,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5644.94,7296,
6.5 X75MM TI CANNULATED SCREW,4400359,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5645.94,7297,
6.5 X80MM TI CANNULATED SCREW,4400360,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5646.94,7298,
6.5 X85MM TI CANNULATED SCREW,4400361,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,813,487.8,,853.65,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,285.77,35.15,,228.616,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,308.94,38,,247.152,percent of total billed charges,38% of total billed charges,259.75,31.95,,207.8,percent of total billed charges,31.95% of total billed charges,5647.94,7299,
6.5 X90MM TI CANNULATED SCREW,4400362,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,460,276,,483,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,161.69,35.15,,129.352,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,174.8,38,,139.84,percent of total billed charges,38% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,5648.94,7300,
6.5 X95MM TI CANNULATED SCREW,4400363,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5649.94,7301,
6.5 X100MM TI CANNULATED SCREW,4400364,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1175.76,31.95,,940.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5650.94,7302,
6.5 X105MM TI CANNULATED SCREW,4400365,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1246.05,31.95,,996.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5651.94,7303,
6.5 X110MM TI CANNULATED SCREW,4400366,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1246.05,31.95,,996.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5652.94,7304,
6.5 X115MM TI CANNULATED SCREW,4400367,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5653.94,7305,
6.5 X120MM TI CANNULATED SCREW,4400368,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5654.94,7306,
8.0 X 40MM TI CANNULATED SCREW,4400369,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5655.94,7307,
8.0 X 45MM TI CANNULATED SCREW,4400370,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5656.94,7308,
8.0 X 50MM TI CANNULATED SCREW,4400371,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5657.94,7309,
8.0 X 55MM TI CANNULATED SCREW,4400372,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,429,257.4,,450.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,150.79,35.15,,120.632,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,163.02,38,,130.416,percent of total billed charges,38% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,5658.94,7310,
8.0 X 60MM TI CANNULATED SCREW,4400373,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5659.94,7311,
8.0 X 65MM TI CANNULATED SCREW,4400374,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5660.94,7312,
8.0 X 70MM TI CANNULATED SCREW,4400375,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5661.94,7313,
8.0 X 75MM TI CANNULATED SCREW,4400376,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5662.94,7314,
8.0 X 80MM TI CANNULATED SCREW,4400377,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5663.94,7315,
8.0 X 85MM TI CANNULATED SCREW,4400378,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5664.94,7316,
8.0 X 90MM TI CANNULATED SCREW,4400379,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5665.94,7317,
8.0 X 95MM TI CANNULATED SCREW,4400380,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5666.94,7318,
8.0 X100MM TI CANNULATED SCREW,4400381,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5667.94,7319,
8.0 X105MM TI CANNULATED SCREW,4400382,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1367.46,31.95,,1093.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5668.94,7320,
8.0 X110MM TI CANNULATED SCREW,4400383,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1460.12,31.95,,1168.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5669.94,7321,
8.0 X115MM TI CANNULATED SCREW,4400384,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1717.31,31.95,,1373.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5670.94,7322,
8.0 X120MM TI CANNULATED SCREW,4400385,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,1718.91,31.95,,1375.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,5671.94,7323,
Ti ASNIS III WASHER FOR 6.5/8.0mm SCREWS,4400386,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,88,52.8,,92.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,30.93,35.15,,24.744,percent of total billed charges,35.15% of total billed charges,1757.25,31.95,,1405.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.44,38,,26.752,percent of total billed charges,38% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,5672.94,7324,
ASNIS III THREADED GUIDE WIRE 3.2X300mm,4400387,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,267,160.2,,280.35,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,93.85,35.15,,75.08,percent of total billed charges,35.15% of total billed charges,1757.25,31.95,,1405.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,101.46,38,,81.168,percent of total billed charges,38% of total billed charges,85.31,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,5673.94,7325,
ASNIS III CANNULATED 6.5mm TWIST DRILL,4400388,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,895,537,,939.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,314.59,35.15,,251.672,percent of total billed charges,35.15% of total billed charges,1757.25,31.95,,1405.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,340.1,38,,272.08,percent of total billed charges,38% of total billed charges,285.95,31.95,,228.76,percent of total billed charges,31.95% of total billed charges,5674.94,7326,
CANNULATED DRILL 6.5mm LG AO FITTING,4400389,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,134.1,80.46,,140.81,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.14,35.15,,37.712,percent of total billed charges,35.15% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.96,38,,40.768,percent of total billed charges,38% of total billed charges,42.84,31.95,,34.272,percent of total billed charges,31.95% of total billed charges,5675.94,7327,
ASNIS III CANNULATED DRILL 5.6mm LG AO,4400390,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,119.85,71.91,,125.84,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.13,35.15,,33.704,percent of total billed charges,35.15% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,45.54,38,,36.432,percent of total billed charges,38% of total billed charges,38.29,31.95,,30.632,percent of total billed charges,31.95% of total billed charges,5676.94,7328,
ASNIS III DRILL BIT 3.2X300mm,4400392,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,297,178.2,,311.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.4,35.15,,83.52,percent of total billed charges,35.15% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,112.86,38,,90.288,percent of total billed charges,38% of total billed charges,94.89,31.95,,75.912,percent of total billed charges,31.95% of total billed charges,5677.94,7329,
HII MRI 10 HOLE PIN CLAMP,4400393,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1696,1017.6,,1780.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,596.14,35.15,,476.912,percent of total billed charges,35.15% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,644.48,38,,515.584,percent of total billed charges,38% of total billed charges,541.87,31.95,,433.496,percent of total billed charges,31.95% of total billed charges,5678.94,7330,
HOFFMANN3 ROD TO ROD COUPLING DIA 5/8/11mm,4400394,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1359,815.4,,1426.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,477.69,35.15,,382.152,percent of total billed charges,35.15% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,516.42,38,,413.136,percent of total billed charges,38% of total billed charges,434.2,31.95,,347.36,percent of total billed charges,31.95% of total billed charges,5679.94,7331,
ROD TO ROD COUPLING MULTIPLANAR HOFFMANN3 ?5/8/11MM,4400395,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,460.35,276.21,,483.37,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,161.81,35.15,,129.448,percent of total billed charges,35.15% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,174.93,38,,139.944,percent of total billed charges,38% of total billed charges,147.08,31.95,,117.664,percent of total billed charges,31.95% of total billed charges,5680.94,7332,
HOFFMANN3 PIN TO ROD COUPLING DIA 4/5/6mm DIA5/8/11mm,4400396,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1240,744,,1302,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,435.86,35.15,,348.688,percent of total billed charges,35.15% of total billed charges,1853.1,31.95,,1482.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,471.2,38,,376.96,percent of total billed charges,38% of total billed charges,396.18,31.95,,316.944,percent of total billed charges,31.95% of total billed charges,5681.94,7333,
HOFFMANN3 PIN TO ROD COUPLING INVERTED DIA 4/5/6mm DIA 5/8/11mm,4400397,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1358,814.8,,1425.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,477.34,35.15,,381.872,percent of total billed charges,35.15% of total billed charges,1908.69,31.95,,1526.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,516.04,38,,412.832,percent of total billed charges,38% of total billed charges,433.88,31.95,,347.104,percent of total billed charges,31.95% of total billed charges,5682.94,7334,
HOFFMANN3 5 HOLE PIN CLAMP DIA 4/5/6mm,4400398,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1400,840,,1470,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,492.1,35.15,,393.68,percent of total billed charges,35.15% of total billed charges,1909.01,31.95,,1527.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,532,38,,425.6,percent of total billed charges,38% of total billed charges,447.3,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,5683.94,7335,
HOFFMANN3 POST STRAIGHT DIA 11mm,4400399,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,380,228,,399,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,106.856,percent of total billed charges,35.15% of total billed charges,1982.5,31.95,,1586,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,144.4,38,,115.52,percent of total billed charges,38% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,5684.94,7336,
HOFFMANN3 POST 30 DEG ANGLED DIA 11mm,4400400,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,327,196.2,,343.35,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,114.94,35.15,,91.952,percent of total billed charges,35.15% of total billed charges,2404.24,31.95,,1923.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,124.26,38,,99.408,percent of total billed charges,38% of total billed charges,104.48,31.95,,83.584,percent of total billed charges,31.95% of total billed charges,5685.94,7337,
HOFFMANN3 POST 90 DEG ANGLED DIA 11mm,4400401,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,468,280.8,,491.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,164.5,35.15,,131.6,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,177.84,38,,142.272,percent of total billed charges,38% of total billed charges,149.53,31.95,,119.624,percent of total billed charges,31.95% of total billed charges,5686.94,7338,
HOFFMANN3 5 HOLE PIN CLAMP 2 POSTS 30 DEG DIA 4/5/6mm,4400402,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,377.7,226.62,,396.59,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,132.76,35.15,,106.208,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,143.53,38,,114.824,percent of total billed charges,38% of total billed charges,120.68,31.95,,96.544,percent of total billed charges,31.95% of total billed charges,5687.94,7339,
SEMI-CIRCULAR CURVED ROD HOFFMANN3 ?11X220MM,4400403,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,220.2,132.12,,231.21,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,77.4,35.15,,61.92,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,83.68,38,,66.944,percent of total billed charges,38% of total billed charges,70.35,31.95,,56.28,percent of total billed charges,31.95% of total billed charges,5688.94,7340,
HOFFMANN3 CONNECTING ROD DIA 11X150mm,4400404,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,626,375.6,,657.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,220.04,35.15,,176.032,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,237.88,38,,190.304,percent of total billed charges,38% of total billed charges,200.01,31.95,,160.008,percent of total billed charges,31.95% of total billed charges,5689.94,7341,
HOFFMANN3 CONNECTING ROD DIA 11X250mm,4400405,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,690,414,,724.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,242.54,35.15,,194.032,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,262.2,38,,209.76,percent of total billed charges,38% of total billed charges,220.46,31.95,,176.368,percent of total billed charges,31.95% of total billed charges,5690.94,7342,
HOFFMANN3 CONNECTING ROD DIA 11X350mm,4400406,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,173.4,104.04,,182.07,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,60.95,35.15,,48.76,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,65.89,38,,52.712,percent of total billed charges,38% of total billed charges,55.4,31.95,,44.32,percent of total billed charges,31.95% of total billed charges,5691.94,7343,
HOFFMANN3 CONNECTING ROD DIA 11X400mm,4400407,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,198.3,118.98,,208.22,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.7,35.15,,55.76,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,75.35,38,,60.28,percent of total billed charges,38% of total billed charges,63.36,31.95,,50.688,percent of total billed charges,31.95% of total billed charges,5692.94,7344,
HOFFMANN3 CONNECTING ROD DIA 11X450mm,4400408,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1080,648,,1134,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,379.62,35.15,,303.696,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,410.4,38,,328.32,percent of total billed charges,38% of total billed charges,345.06,31.95,,276.048,percent of total billed charges,31.95% of total billed charges,5693.94,7345,
5X120 APEX S/D HALF PIN 35 THR,4400409,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,5694.94,7346,
5X150 APEX S/D HALF PIN 40 THR,4400410,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,400,240,,420,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,112.48,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,152,38,,121.6,percent of total billed charges,38% of total billed charges,127.8,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,5695.94,7347,
5X180 APEX S/D HALF PIN 50 THR,4400411,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,404,242.4,,424.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,113.608,percent of total billed charges,35.15% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,153.52,38,,122.816,percent of total billed charges,38% of total billed charges,129.08,31.95,,103.264,percent of total billed charges,31.95% of total billed charges,5696.94,7348,
5X200 APEX S/D HALF PIN 60 THR,4400412,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,350,210,,367.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,98.424,percent of total billed charges,35.15% of total billed charges,2904.89,31.95,,2323.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,5697.94,7349,
5X250 APEX S/D HALF PIN 70 THR,4400413,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,303,181.8,,318.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,106.5,35.15,,85.2,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,115.14,38,,92.112,percent of total billed charges,38% of total billed charges,96.81,31.95,,77.448,percent of total billed charges,31.95% of total billed charges,5698.94,7350,
SELF-DRILLING HALF PIN APEX DIA 3/5mm X 20mm X 120mm,4400414,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,315,189,,330.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,110.72,35.15,,88.576,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,119.7,38,,95.76,percent of total billed charges,38% of total billed charges,100.64,31.95,,80.512,percent of total billed charges,31.95% of total billed charges,5699.94,7351,
APEX TRANSFIX 4X250 PIN 5X50THR,4400415,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72.9,43.74,,76.55,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.62,35.15,,20.496,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.7,38,,22.16,percent of total billed charges,38% of total billed charges,23.29,31.95,,18.632,percent of total billed charges,31.95% of total billed charges,5700.94,7352,
GRAY PT DRILL 3.2mmX200mm,4400416,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,54.6,32.76,,57.33,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.19,35.15,,15.352,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.75,38,,16.6,percent of total billed charges,38% of total billed charges,17.44,31.95,,13.952,percent of total billed charges,31.95% of total billed charges,5701.94,7353,
GRAY PT DRILL 4.0mmX200mm,4400417,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55.5,33.3,,58.28,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.51,35.15,,15.608,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.09,38,,16.872,percent of total billed charges,38% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,5702.94,7354,
GRAY PT DRILL 4.5mmX200mm,4400418,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55.5,33.3,,58.28,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.51,35.15,,15.608,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.09,38,,16.872,percent of total billed charges,38% of total billed charges,17.73,31.95,,14.184,percent of total billed charges,31.95% of total billed charges,5703.94,7355,
127 SIZE 6 SECUR-FIT ADVANCED STEM,4400419,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5500,3300,,5775,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1933.25,35.15,,1546.6,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2090,38,,1672,percent of total billed charges,38% of total billed charges,1757.25,31.95,,1405.8,percent of total billed charges,31.95% of total billed charges,5704.94,7356,
CLUSTERHOLE ACETABULAR SHELL TRIDENT II TRITANIUM,4400420,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,5705.94,7357,
TRIDENT 10 X3 POLYETHYLENE INSERT 32MM ID,4400421,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5706.94,7358,
V40 COCR LFIT FEMORAL HEAD 32MM/+8,4400422,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1700,1020,,1785,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,478.04,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,646,38,,516.8,percent of total billed charges,38% of total billed charges,543.15,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,5707.94,7359,
NECK ANGLE HIP STEM SIZE 9 SECUR-FIT ADVANCED,4400423,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5500,3300,,5775,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1933.25,35.15,,1546.6,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2090,38,,1672,percent of total billed charges,38% of total billed charges,1757.25,31.95,,1405.8,percent of total billed charges,31.95% of total billed charges,5708.94,7360,
CLUSTERHOLE ACETABULAR SHELL TRIDENT II TRITANIUM 62MM,4400424,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,5709.94,7361,
10 DEGREE POLYETHYLENE INSERT 36MM,4400425,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5710.94,7362,
CERAMIC V40 FEMORAL HEAL BIOLOX DELTA 36MM,4400426,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1700,1020,,1785,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,597.55,35.15,,478.04,percent of total billed charges,35.15% of total billed charges,671.91,31.95,,537.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,646,38,,516.8,percent of total billed charges,38% of total billed charges,543.15,31.95,,434.52,percent of total billed charges,31.95% of total billed charges,5711.94,7363,
TRIATHLON POSTERIOR STABILIZED FEMORAL,4400427,CDM,278,RC,,,OUTPATIENT,,,5400,3240,,5670,105,,,case rate,pays based on 105% of threshold rate,2700,50,,2160,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,2700,50,,2160,percent of total billed charges,50% of total billed charges,1725.3,31.95,,1380.24,percent of total billed charges,31.95% of total billed charges,1725.3,31.95,,1380.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2052,38,,1641.6,percent of total billed charges,38% of total billed charges,2160,40,,1728,percent of total billed charges,40% of total billed charges,5712.94,7364,
TRIATHLON PRIMARY TIBIAL BASEPLATE@,4400428,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3300,1980,,3465,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1159.95,35.15,,927.96,percent of total billed charges,35.15% of total billed charges,681.91,31.95,,545.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1254,38,,1003.2,percent of total billed charges,38% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,5713.94,7365,
TRIATHLON X3 TIBIAL BEARING INSERT-PS,4400429,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3900,2340,,4095,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1370.85,35.15,,1096.68,percent of total billed charges,35.15% of total billed charges,747.63,31.95,,598.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1482,38,,1185.6,percent of total billed charges,38% of total billed charges,1246.05,31.95,,996.84,percent of total billed charges,31.95% of total billed charges,5714.94,7366,
TRIATHLON X3 SYMMETRIC PATELLA,4400430,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2400,1440,,2520,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,843.6,35.15,,674.88,percent of total billed charges,35.15% of total billed charges,894.6,31.95,,715.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,912,38,,729.6,percent of total billed charges,38% of total billed charges,766.8,31.95,,613.44,percent of total billed charges,31.95% of total billed charges,5715.94,7367,
ANTIBIOTIC SIMPLEX P BONE CEMENT,4400431,CDM,272,RC,,,OUTPATIENT,,,1041,624.6,,884.85,85,,707.88,Percent of total billed charges,85% of total billed charges,520.5,50,,416.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,520.5,50,,416.4,percent of total billed charges,50% of total billed charges,332.6,31.95,,266.08,percent of total billed charges,31.95% of total billed charges,332.6,31.95,,266.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,395.58,38,,316.464,percent of total billed charges,38% of total billed charges,416.4,40,,333.12,percent of total billed charges,40% of total billed charges,5716.94,7368,
1.9 DRILL,4400432,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,336,201.6,,352.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,118.1,35.15,,94.48,percent of total billed charges,35.15% of total billed charges,77.3,31.95,,61.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.68,38,,102.144,percent of total billed charges,38% of total billed charges,107.35,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,5717.94,7369,
2.3 NONLOCK SCREW 6MM,4400433,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,267,160.2,,280.35,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,93.85,35.15,,75.08,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,101.46,38,,81.168,percent of total billed charges,38% of total billed charges,85.31,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,5718.94,7370,
2.3 NONLOCK SCREW 9MM,4400434,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,267,160.2,,280.35,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,93.85,35.15,,75.08,percent of total billed charges,35.15% of total billed charges,215.66,31.95,,172.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,101.46,38,,81.168,percent of total billed charges,38% of total billed charges,85.31,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,5719.94,7371,
2.3 NONLOCK SCREW 10MM,4400435,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,267,160.2,,280.35,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,93.85,35.15,,75.08,percent of total billed charges,35.15% of total billed charges,24.9,31.95,,19.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,101.46,38,,81.168,percent of total billed charges,38% of total billed charges,85.31,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,5720.94,7372,
2.3 LOCKING SCREW 10MM,4400436,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,309,185.4,,324.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.61,35.15,,86.888,percent of total billed charges,35.15% of total billed charges,373.82,31.95,,299.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.42,38,,93.936,percent of total billed charges,38% of total billed charges,98.73,31.95,,78.984,percent of total billed charges,31.95% of total billed charges,5721.94,7373,
2.3 LOCKING SCREW 8MM,4400437,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,309,185.4,,324.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.61,35.15,,86.888,percent of total billed charges,35.15% of total billed charges,60.07,31.95,,48.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.42,38,,93.936,percent of total billed charges,38% of total billed charges,98.73,31.95,,78.984,percent of total billed charges,31.95% of total billed charges,5722.94,7374,
2.3 LOCKING SCREW 11MM,4400438,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,309,185.4,,324.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.61,35.15,,86.888,percent of total billed charges,35.15% of total billed charges,734.85,31.95,,587.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.42,38,,93.936,percent of total billed charges,38% of total billed charges,98.73,31.95,,78.984,percent of total billed charges,31.95% of total billed charges,5723.94,7375,
Y PLATE 2.3MM,4400439,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1482,889.2,,1556.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,520.92,35.15,,416.736,percent of total billed charges,35.15% of total billed charges,46.97,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,563.16,38,,450.528,percent of total billed charges,38% of total billed charges,473.5,31.95,,378.8,percent of total billed charges,31.95% of total billed charges,5724.94,7376,
BIT DRILL TWIST 1.4MM DIA 27MML AO J-LATCH END HOLEX4,4400440,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,336,201.6,,352.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,118.1,35.15,,94.48,percent of total billed charges,35.15% of total billed charges,46.97,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,127.68,38,,102.144,percent of total billed charges,38% of total billed charges,107.35,31.95,,85.88,percent of total billed charges,31.95% of total billed charges,5725.94,7377,
1.7MM BONE SCREW 8MM,4400441,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,267,160.2,,280.35,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,93.85,35.15,,75.08,percent of total billed charges,35.15% of total billed charges,363.38,31.95,,290.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,101.46,38,,81.168,percent of total billed charges,38% of total billed charges,85.31,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,5726.94,7378,
4 HOLE LEFT OLECRANON PLATE 89MML,4400442,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1906,1143.6,,2001.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,669.96,35.15,,535.968,percent of total billed charges,35.15% of total billed charges,97.45,31.95,,77.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,724.28,38,,579.424,percent of total billed charges,38% of total billed charges,608.97,31.95,,487.176,percent of total billed charges,31.95% of total billed charges,5727.94,7379,
GUIDEWIRE ORTHOPEDIC 1.4MM DIA 150MML THREADED FLAT TROCAR P,4400443,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,285,171,,299.25,105,,,case rate,pays based on 105% of threshold rate,142.5,50,,114,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,142.5,50,,114,percent of total billed charges,50% of total billed charges,100.18,35.15,,80.144,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,108.3,38,,86.64,percent of total billed charges,38% of total billed charges,91.06,31.95,,72.848,percent of total billed charges,31.95% of total billed charges,5728.94,7380,
4.0 CANN SCREW 50MM,4400444,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,5729.94,7381,
K-WIRE 1.2MM,4400445,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,102,61.2,,107.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.85,35.15,,28.68,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38.76,38,,31.008,percent of total billed charges,38% of total billed charges,32.59,31.95,,26.072,percent of total billed charges,31.95% of total billed charges,5730.94,7382,
DRILL SURGICAL CANNULATED 2.1MM DIA,4400446,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,792,475.2,,831.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,278.39,35.15,,222.712,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,300.96,38,,240.768,percent of total billed charges,38% of total billed charges,253.04,31.95,,202.432,percent of total billed charges,31.95% of total billed charges,5731.94,7383,
COUNTERSINK DRILL 3MM DIA CANNULATED F/3MM SCREW,4400447,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,744,446.4,,781.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,261.52,35.15,,209.216,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,282.72,38,,226.176,percent of total billed charges,38% of total billed charges,237.71,31.95,,190.168,percent of total billed charges,31.95% of total billed charges,5732.94,7384,
SCREW BONE CANNULATED 3MM DIA MICRO 15MML,4400448,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,594,356.4,,623.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,208.79,35.15,,167.032,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,225.72,38,,180.576,percent of total billed charges,38% of total billed charges,189.78,31.95,,151.824,percent of total billed charges,31.95% of total billed charges,5733.94,7385,
SCREW BONE CANNULATED 3MM DIA MICRO 13MML,4400449,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,594,356.4,,623.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,208.79,35.15,,167.032,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,225.72,38,,180.576,percent of total billed charges,38% of total billed charges,189.78,31.95,,151.824,percent of total billed charges,31.95% of total billed charges,5734.94,7386,
CRUCIATE RETAINING FEMORAL,4400450,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,5400,3240,,5670,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1898.1,35.15,,1518.48,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2052,38,,1641.6,percent of total billed charges,38% of total billed charges,1725.3,31.95,,1380.24,percent of total billed charges,31.95% of total billed charges,5735.94,7387,
PRIMARY TIBIAL BASEPLATE,4400451,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3300,1980,,3465,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1159.95,35.15,,927.96,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1254,38,,1003.2,percent of total billed charges,38% of total billed charges,1054.35,31.95,,843.48,percent of total billed charges,31.95% of total billed charges,5736.94,7388,
TIBIAL BEARING INSERT-CR,4400452,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3900,2340,,4095,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1370.85,35.15,,1096.68,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1482,38,,1185.6,percent of total billed charges,38% of total billed charges,1246.05,31.95,,996.84,percent of total billed charges,31.95% of total billed charges,5737.94,7389,
SIMPLEX HV WITH GENTAMICIN,4400453,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,519,311.4,,544.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,182.43,35.15,,145.944,percent of total billed charges,35.15% of total billed charges,137.39,31.95,,109.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,197.22,38,,157.776,percent of total billed charges,38% of total billed charges,165.82,31.95,,132.656,percent of total billed charges,31.95% of total billed charges,5738.94,7390,
NECK ANGLE V40 127 DEGREE HIP STEM,4400454,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4000,2400,,4200,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1406,35.15,,1124.8,percent of total billed charges,35.15% of total billed charges,207.68,31.95,,166.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1520,38,,1216,percent of total billed charges,38% of total billed charges,1278,31.95,,1022.4,percent of total billed charges,31.95% of total billed charges,5739.94,7391,
FEMORAL HEAD CERAMIC V40,4400455,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3000,1800,,3150,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1054.5,35.15,,843.6,percent of total billed charges,35.15% of total billed charges,349.97,31.95,,279.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1140,38,,912,percent of total billed charges,38% of total billed charges,958.5,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,5740.94,7392,
HEX SCREW 6.5MM LOW PROFILE 20mm,4400456,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,318,190.8,,333.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,111.78,35.15,,89.424,percent of total billed charges,35.15% of total billed charges,455.01,31.95,,364.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,120.84,38,,96.672,percent of total billed charges,38% of total billed charges,101.6,31.95,,81.28,percent of total billed charges,31.95% of total billed charges,5741.94,7393,
TRIDENT II CLUSTERHOLE ACETABULAR SHELL,4400457,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3000,1800,,3150,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1054.5,35.15,,843.6,percent of total billed charges,35.15% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1140,38,,912,percent of total billed charges,38% of total billed charges,958.5,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,5742.94,7394,
HIP STEM V40 132 DEGREE NECK ANGLE,4400458,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,5000,3000,,5250,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1757.5,35.15,,1406,percent of total billed charges,35.15% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1900,38,,1520,percent of total billed charges,38% of total billed charges,1597.5,31.95,,1278,percent of total billed charges,31.95% of total billed charges,5743.94,7395,
TRIDENT X3 10 DEGREE POLYETHYLENE INSERT,4400459,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3000,1800,,3150,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1054.5,35.15,,843.6,percent of total billed charges,35.15% of total billed charges,20.13,31.95,,16.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1140,38,,912,percent of total billed charges,38% of total billed charges,958.5,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,5744.94,7396,
FEMORAL HEAL CERAMIC V40 36MM X +0MM,4400460,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3000,1800,,3150,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1054.5,35.15,,843.6,percent of total billed charges,35.15% of total billed charges,28.44,31.95,,22.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1140,38,,912,percent of total billed charges,38% of total billed charges,958.5,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,5745.94,7397,
HEX SCREW 6.5MM LOW PROFILE 30mm,4400461,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,318,190.8,,333.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,111.78,35.15,,89.424,percent of total billed charges,35.15% of total billed charges,4.15,31.95,,3.32,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,120.84,38,,96.672,percent of total billed charges,38% of total billed charges,101.6,31.95,,81.28,percent of total billed charges,31.95% of total billed charges,5746.94,7398,
T2 KWIRE,4400462,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,386,231.6,,405.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,108.544,percent of total billed charges,35.15% of total billed charges,6.07,31.95,,4.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,146.68,38,,117.344,percent of total billed charges,38% of total billed charges,123.33,31.95,,98.664,percent of total billed charges,31.95% of total billed charges,5747.94,7399,
CRUCIATE RETAINING FEMORAL #5 RT,4400463,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4500,2700,,4725,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1581.75,35.15,,1265.4,percent of total billed charges,35.15% of total billed charges,10.86,31.95,,8.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1710,38,,1368,percent of total billed charges,38% of total billed charges,1437.75,31.95,,1150.2,percent of total billed charges,31.95% of total billed charges,5748.94,7400,
PRIMARY TIBIAL BASEPLATE #5,4400464,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3000,1800,,3150,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1054.5,35.15,,843.6,percent of total billed charges,35.15% of total billed charges,10.86,31.95,,8.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1140,38,,912,percent of total billed charges,38% of total billed charges,958.5,31.95,,766.8,percent of total billed charges,31.95% of total billed charges,5749.94,7401,
TIBIAL BEARING INSERT - CR #5 19MM,4400465,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3250,1950,,3412.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1142.38,35.15,,913.904,percent of total billed charges,35.15% of total billed charges,10.86,31.95,,8.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1235,38,,988,percent of total billed charges,38% of total billed charges,1038.38,31.95,,830.704,percent of total billed charges,31.95% of total billed charges,5750.94,7402,
SCREW BONE CANNULATED 4MM DIA 46MML,4400466,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,33.87,31.95,,27.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,5751.94,7403,
POSTERIOR STABILIZED FEMORAL #5,4400467,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4500,2700,,4725,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1581.75,35.15,,1265.4,percent of total billed charges,35.15% of total billed charges,37.7,31.95,,30.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1710,38,,1368,percent of total billed charges,38% of total billed charges,1437.75,31.95,,1150.2,percent of total billed charges,31.95% of total billed charges,5752.94,7404,
TIBIAL BEARING INSERT - PS #4,4400468,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3250,1950,,3412.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1142.38,35.15,,913.904,percent of total billed charges,35.15% of total billed charges,37.7,31.95,,30.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1235,38,,988,percent of total billed charges,38% of total billed charges,1038.38,31.95,,830.704,percent of total billed charges,31.95% of total billed charges,5753.94,7405,
SYMMETRIC PATELLA SZE S33MM X 9MM,4400469,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1500,900,,1575,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,527.25,35.15,,421.8,percent of total billed charges,35.15% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,570,38,,456,percent of total billed charges,38% of total billed charges,479.25,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,5754.94,7406,
SHAVER BLADE AGGRESSIVE 6-FLUTE BARREL BUR 4.0MM X 125MM,4400470,CDM,272,RC,,,OUTPATIENT,,,145,87,,123.25,85,,98.6,Percent of total billed charges,85% of total billed charges,72.5,50,,58,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,72.5,50,,58,percent of total billed charges,50% of total billed charges,46.33,31.95,,37.064,percent of total billed charges,31.95% of total billed charges,46.33,31.95,,37.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.1,38,,44.08,percent of total billed charges,38% of total billed charges,58,40,,46.4,percent of total billed charges,40% of total billed charges,5755.94,7407,
2 X 4 PROLAYER,4400471,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1623,973.8,,1704.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,570.48,35.15,,456.384,percent of total billed charges,35.15% of total billed charges,463.28,31.95,,370.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,616.74,38,,493.392,percent of total billed charges,38% of total billed charges,518.55,31.95,,414.84,percent of total billed charges,31.95% of total billed charges,5756.94,7408,
127 8# SECUR FIT ADVANCED STEM,4400472,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5757.94,7409,
HEX SCREW 6.5 X 25MM,4400473,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,159,95.4,,166.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.89,35.15,,44.712,percent of total billed charges,35.15% of total billed charges,162.95,31.95,,130.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.42,38,,48.336,percent of total billed charges,38% of total billed charges,50.8,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,5758.94,7410,
KWIRE 3 X 285,4400474,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,248,148.8,,260.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,87.17,35.15,,69.736,percent of total billed charges,35.15% of total billed charges,44.27,31.95,,35.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,94.24,38,,75.392,percent of total billed charges,38% of total billed charges,79.24,31.95,,63.392,percent of total billed charges,31.95% of total billed charges,5759.94,7411,
KWIRE,4400475,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,116,69.6,,121.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.77,35.15,,32.616,percent of total billed charges,35.15% of total billed charges,46.11,31.95,,36.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.08,38,,35.264,percent of total billed charges,38% of total billed charges,37.06,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,5760.94,7412,
10CC HYDROSET,4400476,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4823,2893.8,,5064.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1695.28,35.15,,1356.224,percent of total billed charges,35.15% of total billed charges,46.11,31.95,,36.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1832.74,38,,1466.192,percent of total billed charges,38% of total billed charges,1540.95,31.95,,1232.76,percent of total billed charges,31.95% of total billed charges,5761.94,7413,
15CC HYDROSET,4400477,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,6918,4150.8,,7263.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2431.68,35.15,,1945.344,percent of total billed charges,35.15% of total billed charges,46.73,31.95,,37.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2628.84,38,,2103.072,percent of total billed charges,38% of total billed charges,2210.3,31.95,,1768.24,percent of total billed charges,31.95% of total billed charges,5762.94,7414,
SECUR-FIT ADVANCED STEM #7 127 DEGREE HIP,4400478,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5763.94,7415,
CLUSTERHOLE ACETABULAR SHELL  SZ 58MM,4400479,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,24.92,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5764.94,7416,
TRIDENT X3 10 DEGREE POLYETHYLENE INSERT 36MM F,4400480,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,74.76,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5765.94,7417,
5.5MM iNTRALINE ANCHOR TWO STRANDS #2 FORCE FIBER,4400481,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,640,384,,672,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,224.96,35.15,,179.968,percent of total billed charges,35.15% of total billed charges,11.49,31.95,,9.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,243.2,38,,194.56,percent of total billed charges,38% of total billed charges,204.48,31.95,,163.584,percent of total billed charges,31.95% of total billed charges,5766.94,7418,
18122A62 -  ACL PACK,4400482,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,386,231.6,,405.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,135.68,35.15,,108.544,percent of total billed charges,35.15% of total billed charges,137.07,31.95,,109.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,146.68,38,,117.344,percent of total billed charges,38% of total billed charges,123.33,31.95,,98.664,percent of total billed charges,31.95% of total billed charges,5767.94,7419,
16P06 - VERSITOMIZ PIN,4400483,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,539,323.4,,565.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,189.46,35.15,,151.568,percent of total billed charges,35.15% of total billed charges,13.96,31.95,,11.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,204.82,38,,163.856,percent of total billed charges,38% of total billed charges,172.21,31.95,,137.768,percent of total billed charges,31.95% of total billed charges,5768.94,7420,
IMPLANT LOOP 25MM,4400484,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,363,217.8,,381.15,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,127.59,35.15,,102.072,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,137.94,38,,110.352,percent of total billed charges,38% of total billed charges,115.98,31.95,,92.784,percent of total billed charges,31.95% of total billed charges,5769.94,7421,
SCREW 10MM X 28MM BIOSTEON,4400485,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,304,182.4,,319.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,106.86,35.15,,85.488,percent of total billed charges,35.15% of total billed charges,234.26,31.95,,187.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,115.52,38,,92.416,percent of total billed charges,38% of total billed charges,97.13,31.95,,77.704,percent of total billed charges,31.95% of total billed charges,5770.94,7422,
JRF SPEEDGRAFT 9 X 226,4400486,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3488,2092.8,,3662.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1226.03,35.15,,980.824,percent of total billed charges,35.15% of total billed charges,16.61,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1325.44,38,,1060.352,percent of total billed charges,38% of total billed charges,1114.42,31.95,,891.536,percent of total billed charges,31.95% of total billed charges,5771.94,7423,
JRF SPEEDGRAFT 9 X 229,4400487,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3488,2092.8,,3662.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1226.03,35.15,,980.824,percent of total billed charges,35.15% of total billed charges,23.43,31.95,,18.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1325.44,38,,1060.352,percent of total billed charges,38% of total billed charges,1114.42,31.95,,891.536,percent of total billed charges,31.95% of total billed charges,5772.94,7424,
POSTERIOR STABILIZED FEMORAL #5 LEFT,4400488,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,5773.94,7425,
POSTERIOR STABILIZED INSERT 4 X 11,4400489,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,647.95,31.95,,518.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5774.94,7426,
4.0 CANN SCREW 42MM,4400490,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,350,210,,367.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,98.424,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,5775.94,7427,
4.0 CANN SCREW 60MM,4400491,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,355,213,,372.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,124.78,35.15,,99.824,percent of total billed charges,35.15% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,134.9,38,,107.92,percent of total billed charges,38% of total billed charges,113.42,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,5776.94,7428,
4.0 CANN SCREW 70MM,4400492,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,350,210,,367.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,98.424,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,5777.94,7429,
"FLIPCUTTER II, SHORT 9MM",4400493,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,600,360,,630,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,210.9,35.15,,168.72,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,182.4,percent of total billed charges,38% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,5778.94,7430,
ACL TIGHTROPE RT,4400494,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,625,375,,656.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,219.69,35.15,,175.752,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,237.5,38,,190,percent of total billed charges,38% of total billed charges,199.69,31.95,,159.752,percent of total billed charges,31.95% of total billed charges,5779.94,7431,
DISPS KIT. TRANS-TIB ACL W/0 SAWBLD,4400495,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,4.52,31.95,,3.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,5780.94,7432,
"10X 30MM BC IF SCREW, VENTED",4400496,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,590,354,,619.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,207.39,35.15,,165.912,percent of total billed charges,35.15% of total billed charges,23.9,31.95,,19.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,224.2,38,,179.36,percent of total billed charges,38% of total billed charges,188.51,31.95,,150.808,percent of total billed charges,31.95% of total billed charges,5781.94,7433,
"#2 FIBERSTICK, #2 FIBERWARE",4400497,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,100,60,,105,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.15,35.15,,28.12,percent of total billed charges,35.15% of total billed charges,24.14,31.95,,19.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38,38,,30.4,percent of total billed charges,38% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,5782.94,7434,
APOLLO RF 90 MULTIPORT,4400498,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,380,228,,399,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,133.57,35.15,,106.856,percent of total billed charges,35.15% of total billed charges,24.9,31.95,,19.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,144.4,38,,115.52,percent of total billed charges,38% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,5783.94,7435,
ACL TIGHTROPE RT W/DEPLOYING SUTURE,4400499,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,700,420,,735,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,246.05,35.15,,196.84,percent of total billed charges,35.15% of total billed charges,55.11,31.95,,44.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,266,38,,212.8,percent of total billed charges,38% of total billed charges,223.65,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,5784.94,7436,
STEINMANN PIN TROCAR PT 1 END PLNSNK 9,4400500,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,57,34.2,,59.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.04,35.15,,16.032,percent of total billed charges,35.15% of total billed charges,11.68,31.95,,9.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,17.328,percent of total billed charges,38% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,5785.94,7437,
TIBIAL BEARING INSERT - CR #5 9MM,4400501,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,14.95,31.95,,11.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5786.94,7438,
ASYMMETRIC PATELLA A35 10MM,4400502,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,17.84,31.95,,14.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5787.94,7439,
CLUSTERHOLE ACETABULAR SHELL #50MM D,4400503,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,18.69,31.95,,14.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5788.94,7440,
CERAMIC V40 FEMORAL HEAL 32MM +4MM,4400504,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,6.23,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5789.94,7441,
REVERSE TENSIONING RT,4400505,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,7.48,31.95,,5.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5790.94,7442,
ALL INSIDE MENSICAL REPAIR DEVICE,4400506,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,9.26,31.95,,7.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5791.94,7443,
PUSHER/WTTER,4400507,CDM,272,RC,,,OUTPATIENT,,,480,288,,408,85,,326.4,Percent of total billed charges,85% of total billed charges,240,50,,192,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,240,50,,192,percent of total billed charges,50% of total billed charges,153.36,31.95,,122.688,percent of total billed charges,31.95% of total billed charges,153.36,31.95,,122.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,182.4,38,,145.92,percent of total billed charges,38% of total billed charges,192,40,,153.6,percent of total billed charges,40% of total billed charges,5792.94,7444,
CRUCIATE RETAINING FEMORAL #6 LEFT,4400508,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,9.26,31.95,,7.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,5793.94,7445,
ASYMMETRIC PATELIA #A32,4400509,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,12.47,31.95,,9.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5794.94,7446,
SCREW BONE CANNULATED 4MM DIA 30MML,4400510,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,350,210,,367.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,98.424,percent of total billed charges,35.15% of total billed charges,17.97,31.95,,14.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,5795.94,7447,
STEINMANN PIN TROCAR PT 1 END,4400511,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,57,34.2,,59.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.04,35.15,,16.032,percent of total billed charges,35.15% of total billed charges,104.74,31.95,,83.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,17.328,percent of total billed charges,38% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,5796.94,7448,
STEINMANN PIN TROCAR PT 1 END.,4400512,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,57,34.2,,59.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.04,35.15,,16.032,percent of total billed charges,35.15% of total billed charges,61.88,31.95,,49.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.66,38,,17.328,percent of total billed charges,38% of total billed charges,18.21,31.95,,14.568,percent of total billed charges,31.95% of total billed charges,5797.94,7449,
TRIATHLON TOTAL KNEE UNIVERSAL TIBIAL BASEPLATE #4,4400513,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2100,1260,,2205,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,738.15,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,77.88,31.95,,62.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,638.4,percent of total billed charges,38% of total billed charges,670.95,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,5798.94,7450,
TRIATHLON X3 TIBIAL BEARING INSERT - PS #4 16MM,4400514,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,748.88,31.95,,599.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5799.94,7451,
TRIATHLON TOTAL KNEE CEMENTED STEM 12MM  100MM,4400515,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1662,997.2,,1745.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,584.19,35.15,,467.352,percent of total billed charges,35.15% of total billed charges,1308.35,31.95,,1046.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,631.56,38,,505.248,percent of total billed charges,38% of total billed charges,531.01,31.95,,424.808,percent of total billed charges,31.95% of total billed charges,5800.94,7452,
TRIATHLON TIBIAL AUGMENT HALF BLOCK #4 10MM,4400516,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1464,878.4,,1537.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,514.6,35.15,,411.68,percent of total billed charges,35.15% of total billed charges,7.72,31.95,,6.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,556.32,38,,445.056,percent of total billed charges,38% of total billed charges,467.75,31.95,,374.2,percent of total billed charges,31.95% of total billed charges,5801.94,7453,
SUTURE 2.0 MONOCRYL CTX NEEDLE 36'',4400517,CDM,272,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,5802.94,7454,
SUTURE 1.0 MONOCRYL CTX NEEDLE 36'',4400518,CDM,272,RC,,,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,5803.94,7455,
THREADED CANNULA 8.0MM X 90MM,4400519,CDM,272,RC,,,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,35,50,,28,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,35,50,,28,percent of total billed charges,50% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,22.37,31.95,,17.896,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.6,38,,21.28,percent of total billed charges,38% of total billed charges,28,40,,22.4,percent of total billed charges,40% of total billed charges,5804.94,7456,
5.5MM PEEK ZIP WITH NEEDLES,4400520,CDM,272,RC,,,OUTPATIENT,,,388,232.8,,329.8,85,,263.84,Percent of total billed charges,85% of total billed charges,194,50,,155.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,194,50,,155.2,percent of total billed charges,50% of total billed charges,123.97,31.95,,99.176,percent of total billed charges,31.95% of total billed charges,123.97,31.95,,99.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.44,38,,117.952,percent of total billed charges,38% of total billed charges,155.2,40,,124.16,percent of total billed charges,40% of total billed charges,5805.94,7457,
2.4MM LOCKING PEG 18MM,4400521,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,250,150,,262.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,70.304,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,38,,76,percent of total billed charges,38% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,5806.94,7458,
SAGITTAL BLADE 18.0MM,4400522,CDM,272,RC,,,OUTPATIENT,,,130,78,,110.5,85,,88.4,Percent of total billed charges,85% of total billed charges,65,50,,52,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,65,50,,52,percent of total billed charges,50% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.4,38,,39.52,percent of total billed charges,38% of total billed charges,52,40,,41.6,percent of total billed charges,40% of total billed charges,5807.94,7459,
LINER-CEMENTLESS 42MM E,4400523,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1580,948,,1659,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,555.37,35.15,,444.296,percent of total billed charges,35.15% of total billed charges,4.14,31.95,,3.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,600.4,38,,480.32,percent of total billed charges,38% of total billed charges,504.81,31.95,,403.848,percent of total billed charges,31.95% of total billed charges,5808.94,7460,
CERAMIC V40 FEMORAL HEAL 28MM +4MM,4400524,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,8.75,31.95,,7,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5809.94,7461,
RESTORATION X3 INSERT FOR ADM/MDM 28MM 28/48 42E,4400525,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2095,1257,,2199.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,736.39,35.15,,589.112,percent of total billed charges,35.15% of total billed charges,12.49,31.95,,9.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,796.1,38,,636.88,percent of total billed charges,38% of total billed charges,669.35,31.95,,535.48,percent of total billed charges,31.95% of total billed charges,5810.94,7462,
CERAMIC V40 FEMORAL HEAL 28MM +0MM,4400526,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,3902.75,31.95,,3122.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5811.94,7463,
ICONIX 1 TT WITH INTELLIBRAID TECH. 1.4MM ANCHOR W/1.2MM X B,4400527,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,600,360,,630,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,210.9,35.15,,168.72,percent of total billed charges,35.15% of total billed charges,2293.15,31.95,,1834.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,182.4,percent of total billed charges,38% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,5812.94,7464,
ICONIX 4.1MM DISPOSABLE DRILL,4400528,CDM,272,RC,,,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,150,50,,120,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,150,50,,120,percent of total billed charges,50% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,120,40,,96,percent of total billed charges,40% of total billed charges,5813.94,7465,
CHAMPION SLINGSHOT 70 UP,4400529,CDM,272,RC,,,OUTPATIENT,,,375,225,,318.75,85,,255,Percent of total billed charges,85% of total billed charges,187.5,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,187.5,50,,150,percent of total billed charges,50% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,142.5,38,,114,percent of total billed charges,38% of total billed charges,150,40,,120,percent of total billed charges,40% of total billed charges,5814.94,7466,
ADVANCED 132 DEG NECK ANAGLE V40 HIP STEM #6 26MM 120MM,4400530,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5815.94,7467,
TRITANIUM CLUSTERHOLE ACETABULAR SHELL 52MM E,4400531,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,4.29,31.95,,3.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5816.94,7468,
6.5MM LOW PROFILE HEX SCREW 6.5MM X 15MM,4400532,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,159,95.4,,166.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.89,35.15,,44.712,percent of total billed charges,35.15% of total billed charges,6.34,31.95,,5.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.42,38,,48.336,percent of total billed charges,38% of total billed charges,50.8,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,5817.94,7469,
AXSOS 3 TI3.5MM CORTEX TI SCREW?3.5MM / L24MM,4400533,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,280,168,,294,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,98.42,35.15,,78.736,percent of total billed charges,35.15% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,106.4,38,,85.12,percent of total billed charges,38% of total billed charges,89.46,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,5818.94,7470,
AXSOS 3 TI4MM LOCKING SCREW4.0MM / L32MM,4400534,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,13.96,31.95,,11.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,5819.94,7471,
SCREW BONE CANNULATED LOCKING 5MM DIA 70MML TITANIUM FULLY T,4400535,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,5820.94,7472,
GUIDEWIRE ORTHOPEDIC 3MM DIA 800MML BALL TIP S2 STERILE,4400536,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,378,226.8,,396.9,105,,,case rate,pays based on 105% of threshold rate,189,50,,151.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,189,50,,151.2,percent of total billed charges,50% of total billed charges,132.87,35.15,,106.296,percent of total billed charges,35.15% of total billed charges,9.32,31.95,,7.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,143.64,38,,114.912,percent of total billed charges,38% of total billed charges,120.77,31.95,,96.616,percent of total billed charges,31.95% of total billed charges,5821.94,7473,
BIT DRILL 4.2MM DIA 130MML,4400537,CDM,272,RC,,,OUTPATIENT,,,280,168,,238,85,,190.4,Percent of total billed charges,85% of total billed charges,140,50,,112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,140,50,,112,percent of total billed charges,50% of total billed charges,89.46,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,89.46,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,106.4,38,,85.12,percent of total billed charges,38% of total billed charges,112,40,,89.6,percent of total billed charges,40% of total billed charges,5822.94,7474,
BIT DRILL 4.2MM DIA 260MML,4400538,CDM,272,RC,,,OUTPATIENT,,,280,168,,238,85,,190.4,Percent of total billed charges,85% of total billed charges,140,50,,112,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,140,50,,112,percent of total billed charges,50% of total billed charges,89.46,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,89.46,31.95,,71.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,106.4,38,,85.12,percent of total billed charges,38% of total billed charges,112,40,,89.6,percent of total billed charges,40% of total billed charges,5823.94,7475,
NAIL INTRAMEDULLARY LOCKING CANNULATED STANDARD 10MM DIA 360,4400539,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2300,1380,,2415,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,808.45,35.15,,646.76,percent of total billed charges,35.15% of total billed charges,9.97,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,874,38,,699.2,percent of total billed charges,38% of total billed charges,734.85,31.95,,587.88,percent of total billed charges,31.95% of total billed charges,5824.94,7476,
SCREW BONE CANNULATED 4MM DIA 40MML,4400540,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,10.03,31.95,,8.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,5825.94,7477,
6.5MM LOW PROFILE HEX SCREW 6.5MM X 35MM,4400541,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,159,95.4,,166.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.89,35.15,,44.712,percent of total billed charges,35.15% of total billed charges,13.06,31.95,,10.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.42,38,,48.336,percent of total billed charges,38% of total billed charges,50.8,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,5826.94,7478,
SCORPION NEEDLE,4400542,CDM,272,RC,,,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,84,percent of total billed charges,50% of total billed charges,67.1,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,67.1,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.8,38,,63.84,percent of total billed charges,38% of total billed charges,84,40,,67.2,percent of total billed charges,40% of total billed charges,5827.94,7479,
BIO-COMP SWVLK C. CLD 4.75X19.1MM,4400543,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,600,360,,630,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,210.9,35.15,,168.72,percent of total billed charges,35.15% of total billed charges,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,182.4,percent of total billed charges,38% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,5828.94,7480,
SECUREFIT ADV 130 NECK V40 HIP STEM #9 34MM 142MM V40,4400544,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,5.5,31.95,,4.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5829.94,7481,
CERAMIC V40 FEMORAL HEAL 32MM -4MM,4400545,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,13.79,31.95,,11.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5830.94,7482,
STRAPS FEMUR/TIBIA TRIANGLE,4400546,CDM,272,RC,,,OUTPATIENT,,,23,13.8,,19.55,85,,15.64,Percent of total billed charges,85% of total billed charges,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,11.5,50,,9.2,percent of total billed charges,50% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,7.35,31.95,,5.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,8.74,38,,6.992,percent of total billed charges,38% of total billed charges,9.2,40,,7.36,percent of total billed charges,40% of total billed charges,5831.94,7483,
6.5MM CANN CREW TI 60MM,4400547,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,553,331.8,,580.65,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,194.38,35.15,,155.504,percent of total billed charges,35.15% of total billed charges,16.26,31.95,,13.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,210.14,38,,168.112,percent of total billed charges,38% of total billed charges,176.68,31.95,,141.344,percent of total billed charges,31.95% of total billed charges,5832.94,7484,
WRIST/THUMB BRACE RIGHT LACE UP UNIVERSAL 12IN,4400549,CDM,272,RC,,,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.28,38,,17.024,percent of total billed charges,38% of total billed charges,22.4,40,,17.92,percent of total billed charges,40% of total billed charges,5833.94,7485,
WRIST/THUMB BRACE LEFT LACE UP UNIVERSAL 12IN,4400550,CDM,272,RC,,,OUTPATIENT,,,56,33.6,,47.6,85,,38.08,Percent of total billed charges,85% of total billed charges,28,50,,22.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,28,50,,22.4,percent of total billed charges,50% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,17.89,31.95,,14.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,21.28,38,,17.024,percent of total billed charges,38% of total billed charges,22.4,40,,17.92,percent of total billed charges,40% of total billed charges,5834.94,7486,
V-LOC 3.0 12IN 1/2 CIRCLE 26MM V-20 GREEN SUTURE,4400551,CDM,272,RC,,,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,29.07,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.58,38,,27.664,percent of total billed charges,38% of total billed charges,36.4,40,,29.12,percent of total billed charges,40% of total billed charges,5835.94,7487,
V-LOC 2.0 12 1/2 CIRCLE 26MM V-20 SUTURE,4400552,CDM,272,RC,,,OUTPATIENT,,,91,54.6,,77.35,85,,61.88,Percent of total billed charges,85% of total billed charges,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45.5,50,,36.4,percent of total billed charges,50% of total billed charges,29.07,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,29.07,31.95,,23.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.58,38,,27.664,percent of total billed charges,38% of total billed charges,36.4,40,,29.12,percent of total billed charges,40% of total billed charges,5836.94,7488,
ANDLE FOOT ORTHOSIS SUPER-LITE MALE RIGHT,4400553,CDM,272,RC,,,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37,50,,29.6,percent of total billed charges,50% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.12,38,,22.496,percent of total billed charges,38% of total billed charges,29.6,40,,23.68,percent of total billed charges,40% of total billed charges,5837.94,7489,
ANKLE FOOT ORTHOSIS SUPER-LITE MALE LEFT,4400554,CDM,272,RC,,,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37,50,,29.6,percent of total billed charges,50% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.12,38,,22.496,percent of total billed charges,38% of total billed charges,29.6,40,,23.68,percent of total billed charges,40% of total billed charges,5838.94,7490,
ANKLE FOOT ORTHOSIS SUPER-LITE FEMALE RIGHT,4400555,CDM,272,RC,,,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37,50,,29.6,percent of total billed charges,50% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.12,38,,22.496,percent of total billed charges,38% of total billed charges,29.6,40,,23.68,percent of total billed charges,40% of total billed charges,5839.94,7491,
ANKLE FOOT ORTHOSIS SUPER-LITE FEMALE LIFT,4400556,CDM,272,RC,,,OUTPATIENT,,,74,44.4,,62.9,85,,50.32,Percent of total billed charges,85% of total billed charges,37,50,,29.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37,50,,29.6,percent of total billed charges,50% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,23.64,31.95,,18.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,28.12,38,,22.496,percent of total billed charges,38% of total billed charges,29.6,40,,23.68,percent of total billed charges,40% of total billed charges,5840.94,7492,
AQUAMANTYS 6.0 BIPOLAR SEALER,4400557,CDM,272,RC,,,OUTPATIENT,,,950,570,,807.5,85,,646,Percent of total billed charges,85% of total billed charges,475,50,,380,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,475,50,,380,percent of total billed charges,50% of total billed charges,303.53,31.95,,242.824,percent of total billed charges,31.95% of total billed charges,303.53,31.95,,242.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,361,38,,288.8,percent of total billed charges,38% of total billed charges,380,40,,304,percent of total billed charges,40% of total billed charges,5841.94,7493,
ORTHOGLASS 3 X 12 PRECUT CASTING,4400559,CDM,272,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,5842.94,7494,
ORTHOGLASS 3 X 35  PRECUT CASTING,4400560,CDM,272,RC,,,OUTPATIENT,,,58,34.8,,49.3,85,,39.44,Percent of total billed charges,85% of total billed charges,29,50,,23.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29,50,,23.2,percent of total billed charges,50% of total billed charges,18.53,31.95,,14.824,percent of total billed charges,31.95% of total billed charges,18.53,31.95,,14.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.04,38,,17.632,percent of total billed charges,38% of total billed charges,23.2,40,,18.56,percent of total billed charges,40% of total billed charges,5843.94,7495,
3.2 X 400 K-WIRE,4400561,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,16.26,31.95,,13.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,5844.94,7496,
T2 RECON STEP DRILL,4400562,CDM,272,RC,,,OUTPATIENT,,,477,286.2,,405.45,85,,324.36,Percent of total billed charges,85% of total billed charges,238.5,50,,190.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,238.5,50,,190.8,percent of total billed charges,50% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,152.4,31.95,,121.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,181.26,38,,145.008,percent of total billed charges,38% of total billed charges,190.8,40,,152.64,percent of total billed charges,40% of total billed charges,5845.94,7497,
11 X 380M X125 RECON NAIL LEFT,4400563,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3190,1914,,3349.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1121.29,35.15,,897.032,percent of total billed charges,35.15% of total billed charges,18.82,31.95,,15.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1212.2,38,,969.76,percent of total billed charges,38% of total billed charges,1019.21,31.95,,815.368,percent of total billed charges,31.95% of total billed charges,5846.94,7498,
6.5 x 75M LAG SCREW,4400564,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,373,223.8,,391.65,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,131.11,35.15,,104.888,percent of total billed charges,35.15% of total billed charges,26.55,31.95,,21.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.74,38,,113.392,percent of total billed charges,38% of total billed charges,119.17,31.95,,95.336,percent of total billed charges,31.95% of total billed charges,5847.94,7499,
T2 RECON SET SCREW,4400565,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,285,171,,299.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,100.18,35.15,,80.144,percent of total billed charges,35.15% of total billed charges,34.08,31.95,,27.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,108.3,38,,86.64,percent of total billed charges,38% of total billed charges,91.06,31.95,,72.848,percent of total billed charges,31.95% of total billed charges,5848.94,7500,
6.5 X 70M LAG SCREW,4400566,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,373,223.8,,391.65,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,131.11,35.15,,104.888,percent of total billed charges,35.15% of total billed charges,40.69,31.95,,32.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,141.74,38,,113.392,percent of total billed charges,38% of total billed charges,119.17,31.95,,95.336,percent of total billed charges,31.95% of total billed charges,5849.94,7501,
BEADED CABLES,4400567,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,482,289.2,,506.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,169.42,35.15,,135.536,percent of total billed charges,35.15% of total billed charges,31.15,31.95,,24.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,183.16,38,,146.528,percent of total billed charges,38% of total billed charges,154,31.95,,123.2,percent of total billed charges,31.95% of total billed charges,5850.94,7502,
BEADED CABLE,4400568,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,450,270,,472.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,126.544,percent of total billed charges,35.15% of total billed charges,31.15,31.95,,24.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,171,38,,136.8,percent of total billed charges,38% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,5851.94,7503,
GUIDE PIN,4400569,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,140,84,,147,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.21,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,99.93,31.95,,79.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,5852.94,7504,
OMEGA COMPRESSION LAG SCREW 13MM DIA 85MML,4400570,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,476,285.6,,499.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,167.31,35.15,,133.848,percent of total billed charges,35.15% of total billed charges,555.11,31.95,,444.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,180.88,38,,144.704,percent of total billed charges,38% of total billed charges,152.08,31.95,,121.664,percent of total billed charges,31.95% of total billed charges,5853.94,7505,
130 DEGREE 2 HOLE OMEGA PLATE,4400571,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,739,443.4,,775.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,259.76,35.15,,207.808,percent of total billed charges,35.15% of total billed charges,37.38,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,280.82,38,,224.656,percent of total billed charges,38% of total billed charges,236.11,31.95,,188.888,percent of total billed charges,31.95% of total billed charges,5854.94,7506,
LAG SCREW 13MM DIA 60MML STAINLESS STEEL OMEGA PLUS STERILE,4400572,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,476,285.6,,499.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,167.31,35.15,,133.848,percent of total billed charges,35.15% of total billed charges,74.76,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,180.88,38,,144.704,percent of total billed charges,38% of total billed charges,152.08,31.95,,121.664,percent of total billed charges,31.95% of total billed charges,5855.94,7507,
SCREW BONE LOCKING 4.5MM DIA 44MML,4400573,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,116,69.6,,121.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.77,35.15,,32.616,percent of total billed charges,35.15% of total billed charges,74.76,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.08,38,,35.264,percent of total billed charges,38% of total billed charges,37.06,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,5856.94,7508,
ASSEMBLY IMPACTOR PLATE F/BASIC LAG SCREW SET OMEGA PLUS,4400574,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,593,355.8,,622.65,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,208.44,35.15,,166.752,percent of total billed charges,35.15% of total billed charges,98.44,31.95,,78.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,225.34,38,,180.272,percent of total billed charges,38% of total billed charges,189.46,31.95,,151.568,percent of total billed charges,31.95% of total billed charges,5857.94,7509,
K-WIRE,4400575,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,294,176.4,,308.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,103.34,35.15,,82.672,percent of total billed charges,35.15% of total billed charges,130.84,31.95,,104.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,111.72,38,,89.376,percent of total billed charges,38% of total billed charges,93.93,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,5858.94,7510,
6.5 X 95M LAG SCREW,4400576,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,2024.26,31.95,,1619.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5859.94,7511,
6.5 X 75M SCREW,4400577,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,455,273,,477.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,159.93,35.15,,127.944,percent of total billed charges,35.15% of total billed charges,2225.59,31.95,,1780.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,172.9,38,,138.32,percent of total billed charges,38% of total billed charges,145.37,31.95,,116.296,percent of total billed charges,31.95% of total billed charges,5860.94,7512,
4.5 X 48M SCREW,4400578,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,116,69.6,,121.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.77,35.15,,32.616,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.08,38,,35.264,percent of total billed charges,38% of total billed charges,37.06,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,5861.94,7513,
Monotube Wrist Kit Yellow Sterile 15X200MM,4400580,CDM,272,RC,,,OUTPATIENT,,,3630,2178,,3085.5,85,,2468.4,Percent of total billed charges,85% of total billed charges,1815,50,,1452,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1815,50,,1452,percent of total billed charges,50% of total billed charges,1159.79,31.95,,927.832,percent of total billed charges,31.95% of total billed charges,1159.79,31.95,,927.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1379.4,38,,1103.52,percent of total billed charges,38% of total billed charges,1452,40,,1161.6,percent of total billed charges,40% of total billed charges,5862.94,7514,
TIBIAL-CHECKPOINT-STERILE,4400582,CDM,272,RC,,,OUTPATIENT,,,147,88.2,,124.95,85,,99.96,Percent of total billed charges,85% of total billed charges,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,73.5,50,,58.8,percent of total billed charges,50% of total billed charges,46.97,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,46.97,31.95,,37.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,55.86,38,,44.688,percent of total billed charges,38% of total billed charges,58.8,40,,47.04,percent of total billed charges,40% of total billed charges,5863.94,7515,
BONE PIN-4MM X 110MM-STERILE 2 PACK,4400583,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,186,111.6,,195.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,65.38,35.15,,52.304,percent of total billed charges,35.15% of total billed charges,11.43,31.95,,9.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.68,38,,56.544,percent of total billed charges,38% of total billed charges,59.43,31.95,,47.544,percent of total billed charges,31.95% of total billed charges,5864.94,7516,
BONE PIN-4MM X 140MM-STERILE 2 PACK,4400584,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,186,111.6,,195.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,65.38,35.15,,52.304,percent of total billed charges,35.15% of total billed charges,12.01,31.95,,9.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.68,38,,56.544,percent of total billed charges,38% of total billed charges,59.43,31.95,,47.544,percent of total billed charges,31.95% of total billed charges,5865.94,7517,
BONE PIN-4MM X 170MM-STERILE 2 PACK,4400585,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,186,111.6,,195.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,65.38,35.15,,52.304,percent of total billed charges,35.15% of total billed charges,12.3,31.95,,9.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,70.68,38,,56.544,percent of total billed charges,38% of total billed charges,59.43,31.95,,47.544,percent of total billed charges,31.95% of total billed charges,5866.94,7518,
SILICONE RETRACTOR CORD,4400587,CDM,272,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,10.032,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,5867.94,7519,
SUTURE TICRON NON-ABSORBABLE POLYESTER 2 30IN DYED REVERSE C,4400590,CDM,272,RC,,,OUTPATIENT,,,59,35.4,,50.15,85,,40.12,Percent of total billed charges,85% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,18.85,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,18.85,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.42,38,,17.936,percent of total billed charges,38% of total billed charges,23.6,40,,18.88,percent of total billed charges,40% of total billed charges,5868.94,7520,
"SUTURE V-Loc 180 Absorbable Wound Closure Device, Green, Si",4400591,CDM,272,RC,,,OUTPATIENT,,,118,70.8,,100.3,85,,80.24,Percent of total billed charges,85% of total billed charges,59,50,,47.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,59,50,,47.2,percent of total billed charges,50% of total billed charges,37.7,31.95,,30.16,percent of total billed charges,31.95% of total billed charges,37.7,31.95,,30.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.84,38,,35.872,percent of total billed charges,38% of total billed charges,47.2,40,,37.76,percent of total billed charges,40% of total billed charges,5869.94,7521,
TRIATHION CRUCIATE RETAINING FEMORAL #4,4400592,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,14.17,31.95,,11.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5870.94,7522,
TRIATHLON X3 TIBIAL BEARING INSERT-CS #4 11MM,4400593,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,10.53,31.95,,8.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5871.94,7523,
TRIATHLON X3 TIBIAL BEARING INSERT-CS #4 16MM,4400594,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,11.72,31.95,,9.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5872.94,7524,
TRIATHLON TOTAL KNEE CEMENTED STEM 12MM X 50MM,4400595,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1662,997.2,,1745.1,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,584.19,35.15,,467.352,percent of total billed charges,35.15% of total billed charges,11.72,31.95,,9.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,631.56,38,,505.248,percent of total billed charges,38% of total billed charges,531.01,31.95,,424.808,percent of total billed charges,31.95% of total billed charges,5873.94,7525,
TRIATHLON CRUCIATE RETAINING FEMORAL #4 RT,4400596,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,22.43,31.95,,17.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5874.94,7526,
TRIATHLON TRITANIUM TIBIAL COMPONENT #5,4400597,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,24.03,31.95,,19.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,5875.94,7527,
TRIATHLON X3 TIBIAL BEARING INSERT - CS #5 13MM,4400598,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,40.89,31.95,,32.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5876.94,7528,
TRIATHLON X3 ASYMMETRIC PATELLA A32 10MM,4400599,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,6.85,31.95,,5.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5877.94,7529,
ORTHOGLASS 4 X 30 PRECUT CASTING,4400600,CDM,272,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,5878.94,7530,
VARIABLE ANGLE FIXATION SCREW,4400601,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,7.76,31.95,,6.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5879.94,7531,
MAKO SAGITTAL BLADE STANDARD,4400602,CDM,272,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,5880.94,7532,
OSCILLIUATING TIP SAW CARTRIDGE,4400603,CDM,272,RC,,,OUTPATIENT,,,700,420,,595,85,,476,Percent of total billed charges,85% of total billed charges,350,50,,280,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,350,50,,280,percent of total billed charges,50% of total billed charges,223.65,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,223.65,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,266,38,,212.8,percent of total billed charges,38% of total billed charges,280,40,,224,percent of total billed charges,40% of total billed charges,5881.94,7533,
"TRUEASK WITH QUICKSAW, LARGE FOOT PLATE",4400604,CDM,272,RC,,,OUTPATIENT,,,270,162,,229.5,85,,183.6,Percent of total billed charges,85% of total billed charges,135,50,,108,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,135,50,,108,percent of total billed charges,50% of total billed charges,86.27,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,86.27,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.6,38,,82.08,percent of total billed charges,38% of total billed charges,108,40,,86.4,percent of total billed charges,40% of total billed charges,5882.94,7534,
2.0 X 300 FLEX NAIL,4400605,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,520,312,,546,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,182.78,35.15,,146.224,percent of total billed charges,35.15% of total billed charges,143.26,31.95,,114.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,197.6,38,,158.08,percent of total billed charges,38% of total billed charges,166.14,31.95,,132.912,percent of total billed charges,31.95% of total billed charges,5883.94,7535,
1.75 X 300 FLEX NAIL,4400606,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,5510.03,31.95,,4408.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5884.94,7536,
TRIATHLON CRUCIATE RETAINING FEMORAL #6,4400607,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5885.94,7537,
TRIATHLON TRITANIUM TIBIAL COMPONENT #6,4400608,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,5886.94,7538,
TRIATHLON X3 TIBIAL BEARING INSERT-CS 6X9MM,4400609,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5887.94,7539,
TRIATHLON X3 ASYMMETRIC PATELLA A38,4400610,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5888.94,7540,
"ACCOLADE II HIP STEM 127, #3",4400611,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5889.94,7541,
TRIDENT II SHELL 46MM,4400612,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5890.94,7542,
TRIDENT X3 INSERT #0 32MM,4400613,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5891.94,7543,
BIOLOX CARAMIC FEMORAL HEAD 32MM  X +110MM,4400614,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5892.94,7544,
SCOPRION MULTI-FIRE NEEDLE,4400615,CDM,272,RC,,,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,125,50,,100,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,125,50,,100,percent of total billed charges,50% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,38,,76,percent of total billed charges,38% of total billed charges,100,40,,80,percent of total billed charges,40% of total billed charges,5893.94,7545,
TRIATHLON X3 TIBIAL INSERT-CS 5 X 16MM,4400616,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5894.94,7546,
ACCOLADE II HIP STEM 127 #2,4400617,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5895.94,7547,
TRIDENT X3 INSERT 0 X 32MM,4400618,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,4.49,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5896.94,7548,
"SCREWDRIVER BLADE T10 AO, SELF RETAINING",4400619,CDM,272,RC,,,OUTPATIENT,,,650,390,,552.5,85,,442,Percent of total billed charges,85% of total billed charges,325,50,,260,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,325,50,,260,percent of total billed charges,50% of total billed charges,207.68,31.95,,166.144,percent of total billed charges,31.95% of total billed charges,207.68,31.95,,166.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,247,38,,197.6,percent of total billed charges,38% of total billed charges,260,40,,208,percent of total billed charges,40% of total billed charges,5897.94,7549,
Saw Blade Oscillating 9MM X 24.6MM X 0.64MM,4400620,CDM,272,RC,,,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,17.5,50,,14,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,17.5,50,,14,percent of total billed charges,50% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,13.3,38,,10.64,percent of total billed charges,38% of total billed charges,14,40,,11.2,percent of total billed charges,40% of total billed charges,5898.94,7550,
"FEMORAL CANAL BRUSH, IRRIGATION/SUCTION",4400621,CDM,272,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,12.16,percent of total billed charges,38% of total billed charges,16,40,,12.8,percent of total billed charges,40% of total billed charges,5899.94,7551,
"QUICK CONNECT 18 X 5.5, 2BLA, 1 PRT",4400622,CDM,272,RC,,,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,50,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,5900.94,7552,
TRIATHLON TIBIAL INSERT #5,4400623,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,4.49,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5901.94,7553,
TRIATHLON X3 PATELLA,4400624,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,5.17,31.95,,4.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5902.94,7554,
OMNIFIT 127 #5 HIP STEM,4400626,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,6.44,31.95,,5.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,5903.94,7555,
TRIDENT TRITANIUM 60MM SHELL,4400627,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5904.94,7556,
LEFT ANATOMIC C-TAPER FEMORAL HEAD 36MM,4400628,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,5905.94,7557,
10MM CEMENT SPACER,4400629,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,168,100.8,,176.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.05,35.15,,47.24,percent of total billed charges,35.15% of total billed charges,6.06,31.95,,4.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.84,38,,51.072,percent of total billed charges,38% of total billed charges,53.68,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,5906.94,7558,
6.5MM X 40MM HEX SCREW,4400630,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,159,95.4,,166.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.89,35.15,,44.712,percent of total billed charges,35.15% of total billed charges,7.02,31.95,,5.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,60.42,38,,48.336,percent of total billed charges,38% of total billed charges,50.8,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,5907.94,7559,
SIMPLEX SPEEDSET CEMENT,4400631,CDM,272,RC,,,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,57.5,50,,46,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57.5,50,,46,percent of total billed charges,50% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,46,40,,36.8,percent of total billed charges,40% of total billed charges,5908.94,7560,
TRIATHLON TRITANIUM TIBIA #4,4400632,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,7.46,31.95,,5.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,5909.94,7561,
TRIATHLON X3 PATELLA A40,4400633,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,8.07,31.95,,6.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5910.94,7562,
"POSITIONER, HEAD FOAM",4400635,CDM,270,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,4.56,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,5911.94,7563,
ORTHOGLASS 4 X 15 PRE-CUTT,4400636,CDM,272,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,5912.94,7564,
ACCOLADE II STEM 132 DEGREE #6,4400637,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,16.38,31.95,,13.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5913.94,7565,
TRIATHLON CR PF FEMORAL #5,4400638,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,17.7,31.95,,14.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5914.94,7566,
TRIATHLON CR PF FEMUR #1,4400639,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,4049.66,31.95,,3239.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5915.94,7567,
TRIATHLON UNIVERSAL BASEPLATE #2,4400640,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2100,1260,,2205,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,738.15,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,531.64,31.95,,425.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,638.4,percent of total billed charges,38% of total billed charges,670.95,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,5916.94,7568,
TRIATHLON X3 SC INSERT #2 16MM,4400641,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5917.94,7569,
THIATHLON X3 PATELLA A29 9MM,4400642,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,732.05,31.95,,585.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5918.94,7570,
ACCOLADE II STEM 127 DEGREE #5,4400643,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,92.55,31.95,,74.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5919.94,7571,
ACCOLADE II STEM 127 DEGREE #4,4400644,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,99.68,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,5920.94,7572,
TRIDENT X3 INSERT 0 DEGREE 36MM,4400645,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,124.61,31.95,,99.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5921.94,7573,
BEAVER GRINDLESS MINIBLADE WITH ROUND TIP #65,4400646,CDM,272,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,5922.94,7574,
ARMBOARD FOAM POSITIONER 3 X 5 X 24,4400647,CDM,272,RC,,,OUTPATIENT,,,17,10.2,,14.45,85,,11.56,Percent of total billed charges,85% of total billed charges,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,8.5,50,,6.8,percent of total billed charges,50% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,5.43,31.95,,4.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,6.46,38,,5.168,percent of total billed charges,38% of total billed charges,6.8,40,,5.44,percent of total billed charges,40% of total billed charges,5923.94,7575,
SUTURE ETHILON NYLON 3.0 30 3/8 CUTTING,4400648,CDM,272,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,5924.94,7576,
SUTURE PROLENE 3.0 30 3/8 CUTTING,4400649,CDM,272,RC,,,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,7.5,50,,6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.5,50,,6,percent of total billed charges,50% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,5.7,38,,4.56,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,5925.94,7577,
MAKO SAGITTAL BLADE NARROW,4400650,CDM,270,RC,,,OUTPATIENT,,,600,360,,510,85,,408,Percent of total billed charges,85% of total billed charges,300,50,,240,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,300,50,,240,percent of total billed charges,50% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,182.4,percent of total billed charges,38% of total billed charges,240,40,,192,percent of total billed charges,40% of total billed charges,5926.94,7578,
TRIATHLON X3 PATELLA S36MM,4400653,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,145.87,31.95,,116.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,5927.94,7579,
TRIATHLON X3 CS INSERT 4 X 9MM,4400654,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,145.87,31.95,,116.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5928.94,7580,
TRIATHLON UNIVERSAL TIBIAL BASEPLATE,4400655,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2100,1260,,2205,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,738.15,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,160.32,31.95,,128.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,638.4,percent of total billed charges,38% of total billed charges,670.95,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,5929.94,7581,
TRIATHLON X3 CS INSERT 3 X 13MM,4400656,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5930.94,7582,
POUCH INSTRUMENT 2-POCKET,4400657,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,5931.94,7583,
TRIATHLON CR PF FEMUR #3,4400658,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,1616.43,31.95,,1293.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5932.94,7584,
THIATHLON CRUCIATE RETAINING FEMORAL #3,4400659,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,348.64,31.95,,278.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5933.94,7585,
LFIT C-TAPER FEMORAL HEAD 36MM,4400660,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,383.41,31.95,,306.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,5934.94,7586,
EGG BUR 4.0 MM,4400661,CDM,272,RC,,,OUTPATIENT,,,144,86.4,,122.4,85,,97.92,Percent of total billed charges,85% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,72,50,,57.6,percent of total billed charges,50% of total billed charges,46.01,31.95,,36.808,percent of total billed charges,31.95% of total billed charges,46.01,31.95,,36.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.72,38,,43.776,percent of total billed charges,38% of total billed charges,57.6,40,,46.08,percent of total billed charges,40% of total billed charges,5935.94,7587,
WRIST FUSION PLATE STRAIGHT 120MM,4400662,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2100,1260,,2205,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,738.15,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,213.82,31.95,,171.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,638.4,percent of total billed charges,38% of total billed charges,670.95,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,5936.94,7588,
TRIATHLON UNIVERSAL TIBIAL BASEPLATE #5,4400663,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2100,1260,,2205,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,738.15,35.15,,590.52,percent of total billed charges,35.15% of total billed charges,213.82,31.95,,171.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,798,38,,638.4,percent of total billed charges,38% of total billed charges,670.95,31.95,,536.76,percent of total billed charges,31.95% of total billed charges,5937.94,7589,
MAYO CATGUT 1/2 CIRCLE TAPER POINT,4400664,CDM,272,RC,,,OUTPATIENT,,,33,19.8,,28.05,85,,22.44,Percent of total billed charges,85% of total billed charges,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,16.5,50,,13.2,percent of total billed charges,50% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,10.54,31.95,,8.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,12.54,38,,10.032,percent of total billed charges,38% of total billed charges,13.2,40,,10.56,percent of total billed charges,40% of total billed charges,5938.94,7590,
SUTURE PACING 1/2 CIRCLE/STRAIGHT 26MM BLUE,4400665,CDM,272,RC,,,OUTPATIENT,,,40,24,,34,85,,27.2,Percent of total billed charges,85% of total billed charges,20,50,,16,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,20,50,,16,percent of total billed charges,50% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,12.78,31.95,,10.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,15.2,38,,12.16,percent of total billed charges,38% of total billed charges,16,40,,12.8,percent of total billed charges,40% of total billed charges,5939.94,7591,
SUTURE ANCHOR CORKSCREW FT 5.5 X 16.3MM,4400666,CDM,272,RC,,,OUTPATIENT,,,490,294,,416.5,85,,333.2,Percent of total billed charges,85% of total billed charges,245,50,,196,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,245,50,,196,percent of total billed charges,50% of total billed charges,156.56,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,156.56,31.95,,125.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,186.2,38,,148.96,percent of total billed charges,38% of total billed charges,196,40,,156.8,percent of total billed charges,40% of total billed charges,5940.94,7592,
BONE WAX 2.5g,4400667,CDM,272,RC,,,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,10,50,,8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10,50,,8,percent of total billed charges,50% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,5941.94,7593,
MCGOWAN NEEDLE 1/2CIR TPR DISP,4400670,CDM,272,RC,,,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,20,percent of total billed charges,50% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,19,38,,15.2,percent of total billed charges,38% of total billed charges,20,40,,16,percent of total billed charges,40% of total billed charges,5942.94,7594,
TRITANIUM #3 TIBIA,4400672,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,5943.94,7595,
TRIATHLON X3 TIBIAL BEARING INSERT 3X11MM,4400673,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5944.94,7596,
HYDRO SET XL,4400674,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4830,2898,,5071.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1697.75,35.15,,1358.2,percent of total billed charges,35.15% of total billed charges,7.46,31.95,,5.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1835.4,38,,1468.32,percent of total billed charges,38% of total billed charges,1543.19,31.95,,1234.552,percent of total billed charges,31.95% of total billed charges,5945.94,7597,
2.5MM DRILL,4400675,CDM,272,RC,,,OUTPATIENT,,,545,327,,463.25,85,,370.6,Percent of total billed charges,85% of total billed charges,272.5,50,,218,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,272.5,50,,218,percent of total billed charges,50% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,207.1,38,,165.68,percent of total billed charges,38% of total billed charges,218,40,,174.4,percent of total billed charges,40% of total billed charges,5946.94,7598,
3.1MM DRILL,4400676,CDM,272,RC,,,OUTPATIENT,,,545,327,,463.25,85,,370.6,Percent of total billed charges,85% of total billed charges,272.5,50,,218,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,272.5,50,,218,percent of total billed charges,50% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,207.1,38,,165.68,percent of total billed charges,38% of total billed charges,218,40,,174.4,percent of total billed charges,40% of total billed charges,5947.94,7599,
K-WIRE 2MM,4400677,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,32.26,31.95,,25.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,5948.94,7600,
10 HOLE PROX TIBIA PLATE LEFT,4400678,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3200,1920,,3360,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1124.8,35.15,,899.84,percent of total billed charges,35.15% of total billed charges,693.3,31.95,,554.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1216,38,,972.8,percent of total billed charges,38% of total billed charges,1022.4,31.95,,817.92,percent of total billed charges,31.95% of total billed charges,5949.94,7601,
3.5 ORTEX SCREW 70MM,4400679,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,140,84,,147,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.21,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,5950.94,7602,
4.0 CANCELLOUS SCREW 70MM,4400680,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,130,78,,136.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,45.7,35.15,,36.56,percent of total billed charges,35.15% of total billed charges,18.2,31.95,,14.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.4,38,,39.52,percent of total billed charges,38% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,5951.94,7603,
4.0 CANCELLOUS SCREW 50MM,4400681,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,130,78,,136.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,45.7,35.15,,36.56,percent of total billed charges,35.15% of total billed charges,20.06,31.95,,16.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.4,38,,39.52,percent of total billed charges,38% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,5952.94,7604,
4.0 CANCELLOUS SCREW 55MM,4400682,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,130,78,,136.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,45.7,35.15,,36.56,percent of total billed charges,35.15% of total billed charges,10.38,31.95,,8.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,49.4,38,,39.52,percent of total billed charges,38% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,5953.94,7605,
4.0 LOCKING SCREW 40MM,4400683,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,12.55,31.95,,10.04,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,5954.94,7606,
TEMP PLATE FIXATOR AO FITTING,4400684,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,600,360,,630,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,210.9,35.15,,168.72,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,228,38,,182.4,percent of total billed charges,38% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,5955.94,7607,
"IMPLANT DELIVERY SYSTEM, TRIM-IT DRILL PIN, 1.5X100MM",4400686,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,700,420,,735,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,246.05,35.15,,196.84,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,266,38,,212.8,percent of total billed charges,38% of total billed charges,223.65,31.95,,178.92,percent of total billed charges,31.95% of total billed charges,5956.94,7608,
COUNTERSINK-13,4400687,CDM,272,RC,,,OUTPATIENT,,,1000,600,,850,85,,680,Percent of total billed charges,85% of total billed charges,500,50,,400,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,500,50,,400,percent of total billed charges,50% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,304,percent of total billed charges,38% of total billed charges,400,40,,320,percent of total billed charges,40% of total billed charges,5957.94,7609,
3.1 DRILL,4400688,CDM,272,RC,,,OUTPATIENT,,,240,144,,204,85,,163.2,Percent of total billed charges,85% of total billed charges,120,50,,96,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,120,50,,96,percent of total billed charges,50% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,76.68,31.95,,61.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,91.2,38,,72.96,percent of total billed charges,38% of total billed charges,96,40,,76.8,percent of total billed charges,40% of total billed charges,5958.94,7610,
NITINOL WIRE,4400689,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,125,75,,131.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,43.94,35.15,,35.152,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.5,38,,38,percent of total billed charges,38% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,5959.94,7611,
GLENOID BASEPLATE,4400690,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5960.94,7612,
32MM GLENOSPHERE +2MM,4400691,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5961.94,7613,
6.5MM X 36MM CENTER SCREW,4400692,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5962.94,7614,
4.5MM X 40MM LOCK SCREW,4400693,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5963.94,7615,
4.5MM X 20MM LOCK SCREW,4400694,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5964.94,7616,
REUNION TSA MODULAR HUMERAL STEM #9,4400695,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5550,3330,,5827.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1950.83,35.15,,1560.664,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2109,38,,1687.2,percent of total billed charges,38% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,5965.94,7617,
REUNION RSA HUMERAL CUP 32MM X 4MM,4400696,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5966.94,7618,
REUNION RSA X3 HUMERAL INSERT,4400697,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5967.94,7619,
3.0 SCREW BONE CANNULATED COMPRESSION 3MM DIA 34MML,4400698,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,740,444,,777,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,260.11,35.15,,208.088,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,281.2,38,,224.96,percent of total billed charges,38% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,5968.94,7620,
ANTIMICROBIAL SKIN WIPE 2% CHLORHEXIDINE GLUCONATE NON-STERI,4400699,CDM,272,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,5969.94,7621,
TRIATHLON TIBIAL #1,4400700,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,5970.94,7622,
TRIATHLON TIBIAL BEARING INSERT #1 9MM,4400701,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5971.94,7623,
TRIATHLON OR FEMUR #2 RT,4400702,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5972.94,7624,
TRIATHLON CR TIBIAL KIT #1,4400703,CDM,272,RC,,,OUTPATIENT,,,380,228,,323,85,,258.4,Percent of total billed charges,85% of total billed charges,190,50,,152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,190,50,,152,percent of total billed charges,50% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,144.4,38,,115.52,percent of total billed charges,38% of total billed charges,152,40,,121.6,percent of total billed charges,40% of total billed charges,5973.94,7625,
36+2 ECC GLENSOPHERE,4400704,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5974.94,7626,
6.5 X 44 CENTER SCREW,4400705,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5975.94,7627,
4.5 x 24 LOCK SCREW,4400706,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5976.94,7628,
4.5 X 16 LOCK SCREW,4400707,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5977.94,7629,
#11 REUNION STEM,4400708,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5550,3330,,5827.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1950.83,35.15,,1560.664,percent of total billed charges,35.15% of total billed charges,3.96,31.95,,3.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2109,38,,1687.2,percent of total billed charges,38% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,5978.94,7630,
36+4 HUMERAL CUP,4400709,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,6.22,31.95,,4.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5979.94,7631,
36+8 HUMERAL INSERT,4400710,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,6.23,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5980.94,7632,
4.5 X 32 LOCK SCREW,4400711,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,6.85,31.95,,5.48,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5981.94,7633,
4.5 X 36 LOCK SCREW,4400712,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,7.03,31.95,,5.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,5982.94,7634,
32+8 HUMERAL INSERT,4400713,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,7.75,31.95,,6.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,5983.94,7635,
4MM CANNULATED SCREW 28MM,4400714,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,7.79,31.95,,6.232,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,5984.94,7636,
4.0MM CANNULATED SCREW 32MM,4400715,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,395,237,,414.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,138.84,35.15,,111.072,percent of total billed charges,35.15% of total billed charges,8.19,31.95,,6.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.1,38,,120.08,percent of total billed charges,38% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,5985.94,7637,
CLAVICLE PLATE 80MML,4400716,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1470,882,,1543.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,516.71,35.15,,413.368,percent of total billed charges,35.15% of total billed charges,8.19,31.95,,6.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,558.6,38,,446.88,percent of total billed charges,38% of total billed charges,469.67,31.95,,375.736,percent of total billed charges,31.95% of total billed charges,5986.94,7638,
"K-LESS T-ROPE W/DRV, SYN REPR, SS",4400717,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2200,1320,,2310,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,773.3,35.15,,618.64,percent of total billed charges,35.15% of total billed charges,9.97,31.95,,7.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,836,38,,668.8,percent of total billed charges,38% of total billed charges,702.9,31.95,,562.32,percent of total billed charges,31.95% of total billed charges,5987.94,7639,
TRIATHLON X3 TIBIAL INSERT 5X11,4400718,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,12.22,31.95,,9.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5988.94,7640,
MEPILEX BORDER POST OP 4 X 12,4400719,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,5989.94,7641,
RIGHT MEDIAL DISTAL HUMERAL PLATE,4400720,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1552,931.2,,1629.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,545.53,35.15,,436.424,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,589.76,38,,471.808,percent of total billed charges,38% of total billed charges,495.86,31.95,,396.688,percent of total billed charges,31.95% of total billed charges,5990.94,7642,
LOCKING SCREW T10 FULL THREAD 3.5mm / L24mm.,4400721,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,5991.94,7643,
4.0 X 65MM CANNULATED SCREW,4400722,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,355,213,,372.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,124.78,35.15,,99.824,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,134.9,38,,107.92,percent of total billed charges,38% of total billed charges,113.42,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,5992.94,7644,
TRIATHLON CR RETAINING FEMORAL #5,4400723,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,5993.94,7645,
TRIATHLON X3 TIBIAL BEARING INSERT-CS #6,4400724,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,5994.94,7646,
TRIATHLON CR TIBIA PREP KIT #4,4400725,CDM,270,RC,,,OUTPATIENT,,,380,228,,323,85,,258.4,Percent of total billed charges,85% of total billed charges,190,50,,152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,190,50,,152,percent of total billed charges,50% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,144.4,38,,115.52,percent of total billed charges,38% of total billed charges,152,40,,121.6,percent of total billed charges,40% of total billed charges,5995.94,7647,
4.0 CANN SCREW 48M,4400726,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,355,213,,372.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,124.78,35.15,,99.824,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,134.9,38,,107.92,percent of total billed charges,38% of total billed charges,113.42,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,5996.94,7648,
4.0 CANN SCREW 55M,4400727,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,5997.94,7649,
TRIDENT II ACE SHELL #56MM,4400728,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,3.86,31.95,,3.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,5998.94,7650,
TRIDENT X3 POLY INSERT #36FMM,4400729,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,3.91,31.95,,3.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,5999.94,7651,
TRIATHLON CR FEMUR #7 RT,4400730,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,3.91,31.95,,3.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,6000.94,7652,
TRIATHLON X3 TIBIA INSERT #6X 11,4400731,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,4.2,31.95,,3.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6001.94,7653,
HELIOCOIDAL RASP 3.2MM X 18.3MM METAL CUTTING,4400732,CDM,272,RC,,,OUTPATIENT,,,395,237,,335.75,85,,268.6,Percent of total billed charges,85% of total billed charges,197.5,50,,158,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,197.5,50,,158,percent of total billed charges,50% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.1,38,,120.08,percent of total billed charges,38% of total billed charges,158,40,,126.4,percent of total billed charges,40% of total billed charges,6002.94,7654,
DISC DIAMOND 25.4MM X 18.3MM METAL CUTTING,4400733,CDM,272,RC,,,OUTPATIENT,,,377,226.2,,320.45,85,,256.36,Percent of total billed charges,85% of total billed charges,188.5,50,,150.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,188.5,50,,150.8,percent of total billed charges,50% of total billed charges,120.45,31.95,,96.36,percent of total billed charges,31.95% of total billed charges,120.45,31.95,,96.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,143.26,38,,114.608,percent of total billed charges,38% of total billed charges,150.8,40,,120.64,percent of total billed charges,40% of total billed charges,6003.94,7655,
K-WIRE FIXATION KIRSCHNER 1MM DIA 150MML STAINLESS STEEL TRO,4400735,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,46,27.6,,48.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.17,35.15,,12.936,percent of total billed charges,35.15% of total billed charges,4.22,31.95,,3.376,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.48,38,,13.984,percent of total billed charges,38% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,6004.94,7656,
SCREW BONE CANNULATED COMPRESSION 2.5MM DIA 26MML AUTOFIX,4400736,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,500,300,,525,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,175.75,35.15,,140.6,percent of total billed charges,35.15% of total billed charges,4.36,31.95,,3.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,6005.94,7657,
TRIATHLON X3 TIBIAL BEARING INSERT #3 X 16,4400737,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,4.4,31.95,,3.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6006.94,7658,
APEX HALF PIN EXTERNAL FIXATION 5MM DIA 150MML,4400738,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,404,242.4,,424.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,142.01,35.15,,113.608,percent of total billed charges,35.15% of total billed charges,4.97,31.95,,3.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,153.52,38,,122.816,percent of total billed charges,38% of total billed charges,129.08,31.95,,103.264,percent of total billed charges,31.95% of total billed charges,6007.94,7659,
3.0  CANNULATED COMPRESSION 18MM,4400739,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,530,318,,556.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,186.3,35.15,,149.04,percent of total billed charges,35.15% of total billed charges,5.53,31.95,,4.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,201.4,38,,161.12,percent of total billed charges,38% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,6008.94,7660,
3.0 CANNULATED SCREW 20MM,4400740,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,530,318,,556.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,186.3,35.15,,149.04,percent of total billed charges,35.15% of total billed charges,7.27,31.95,,5.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,201.4,38,,161.12,percent of total billed charges,38% of total billed charges,169.34,31.95,,135.472,percent of total billed charges,31.95% of total billed charges,6009.94,7661,
K-WIRE 0.9 X 80MM,4400741,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,108,64.8,,113.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,37.96,35.15,,30.368,percent of total billed charges,35.15% of total billed charges,7.7,31.95,,6.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.04,38,,32.832,percent of total billed charges,38% of total billed charges,34.51,31.95,,27.608,percent of total billed charges,31.95% of total billed charges,6010.94,7662,
ACCOLADE II HIP STEM 127 DEGREE #9,4400742,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,29.11,31.95,,23.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6011.94,7663,
FIXATOR EXTERNAL FIXATION 3MM DIA,4400743,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1090,654,,1144.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,383.14,35.15,,306.512,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,414.2,38,,331.36,percent of total billed charges,38% of total billed charges,348.26,31.95,,278.608,percent of total billed charges,31.95% of total billed charges,6012.94,7664,
PLATE BONE LEFT PROXIMAL LATERAL TIBIAL,4400744,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3145,1887,,3302.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1105.47,35.15,,884.376,percent of total billed charges,35.15% of total billed charges,3.89,31.95,,3.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1195.1,38,,956.08,percent of total billed charges,38% of total billed charges,1004.83,31.95,,803.864,percent of total billed charges,31.95% of total billed charges,6013.94,7665,
4.0 X 75 LOCKING SCREW,4400745,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,58.19,31.95,,46.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,6014.94,7666,
4.0 X 38 LOCKING SCREW,4400746,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,9.83,31.95,,7.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,6015.94,7667,
4.0 X 20 LOCKING SCREW,4400747,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,9.83,31.95,,7.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,6016.94,7668,
4.0 LOCKING SCREW 80MM,4400748,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,11.62,31.95,,9.296,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,6017.94,7669,
4.0 LOCKING SCREW 70MM,4400749,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,15.58,31.95,,12.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,6018.94,7670,
TRIATHLON X3 TIBIA INSERT-CS #3 X 9MM,4400750,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,37.78,31.95,,30.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6019.94,7671,
OMNIFIT EON #7/127 DEGREE HIP STEM,4400751,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,37.78,31.95,,30.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6020.94,7672,
UHR BIPOLAR HEAD #18MM X 28MM,4400752,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1350,810,,1417.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,474.53,35.15,,379.624,percent of total billed charges,35.15% of total billed charges,82.24,31.95,,65.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,513,38,,410.4,percent of total billed charges,38% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,6021.94,7673,
C-TAPER LIFT HEAD #28MM + 0,4400753,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1000,600,,1050,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,351.5,35.15,,281.2,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,380,38,,304,percent of total billed charges,38% of total billed charges,319.5,31.95,,255.6,percent of total billed charges,31.95% of total billed charges,6022.94,7674,
UNIVERSAL CEMENT SPACER #13,4400754,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,5.12,31.95,,4.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6023.94,7675,
SET SCREW FEMUR,4400755,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,340,204,,357,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,119.51,35.15,,95.608,percent of total billed charges,35.15% of total billed charges,5.34,31.95,,4.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.2,38,,103.36,percent of total billed charges,38% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,6024.94,7676,
FEMORAL NAIL GT 10 X 360MM,4400756,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3680,2208,,3864,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1293.52,35.15,,1034.816,percent of total billed charges,35.15% of total billed charges,8.41,31.95,,6.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1398.4,38,,1118.72,percent of total billed charges,38% of total billed charges,1175.76,31.95,,940.608,percent of total billed charges,31.95% of total billed charges,6025.94,7677,
LAG SCREW 6.5 X 90MM,4400757,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,375,225,,393.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,131.81,35.15,,105.448,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,142.5,38,,114,percent of total billed charges,38% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,6026.94,7678,
3.2 X 400MM KWIRE DRILL-TIP RECON,4400758,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,320,192,,336,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.48,35.15,,89.984,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.6,38,,97.28,percent of total billed charges,38% of total billed charges,102.24,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,6027.94,7679,
4.2 X 185MM DRILL FREEHAND,4400759,CDM,272,RC,,,OUTPATIENT,,,410,246,,348.5,85,,278.8,Percent of total billed charges,85% of total billed charges,205,50,,164,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,205,50,,164,percent of total billed charges,50% of total billed charges,131,31.95,,104.8,percent of total billed charges,31.95% of total billed charges,131,31.95,,104.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,155.8,38,,124.64,percent of total billed charges,38% of total billed charges,164,40,,131.2,percent of total billed charges,40% of total billed charges,6028.94,7680,
3MM X 285MM KWIRE,4400760,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,250,150,,262.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,87.88,35.15,,70.304,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,38,,76,percent of total billed charges,38% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,6029.94,7681,
3.0 X 24MM SCREW SELF-DRILLING/TAPPING HEADLESS AUTOFIX,4400761,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,400,240,,420,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,140.6,35.15,,112.48,percent of total billed charges,35.15% of total billed charges,4.58,31.95,,3.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,152,38,,121.6,percent of total billed charges,38% of total billed charges,127.8,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,6030.94,7682,
4.0 x 44MM CANN SCREW,4400762,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,395,237,,414.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,138.84,35.15,,111.072,percent of total billed charges,35.15% of total billed charges,4.75,31.95,,3.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.1,38,,120.08,percent of total billed charges,38% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,6031.94,7683,
4.0 x 38MM CANN SCREW,4400763,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,350,210,,367.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,123.03,35.15,,98.424,percent of total billed charges,35.15% of total billed charges,5.38,31.95,,4.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,6032.94,7684,
CAST TAPE 1X2YDS FIBERGLASS WHITE LF,4400764,CDM,270,RC,,,OUTPATIENT,,,12.5,7.5,,10.63,85,,8.504,Percent of total billed charges,85% of total billed charges,6.25,50,,5,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,6.25,50,,5,percent of total billed charges,50% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.75,38,,3.8,percent of total billed charges,38% of total billed charges,5,40,,4,percent of total billed charges,40% of total billed charges,6033.94,7685,
TRIATHLON CRUCLATE RETAINING FEMORAL #3 LEFT,4400765,CDM,270,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2295,85,,1836,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,6.19,31.95,,4.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6034.94,7686,
TRIATHLON TIBIAL CS #4 11MM,4400766,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,15.69,31.95,,12.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,6035.94,7687,
FLEXIBLE OSTEOTOME 12MM X 120MM,4400767,CDM,270,RC,,,OUTPATIENT,,,580,348,,493,85,,394.4,Percent of total billed charges,85% of total billed charges,290,50,,232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,290,50,,232,percent of total billed charges,50% of total billed charges,185.31,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,185.31,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,220.4,38,,176.32,percent of total billed charges,38% of total billed charges,232,40,,185.6,percent of total billed charges,40% of total billed charges,6036.94,7688,
FLEXIBLE OSTEOTOME 12MM X 93MM,4400768,CDM,270,RC,,,OUTPATIENT,,,580,348,,493,85,,394.4,Percent of total billed charges,85% of total billed charges,290,50,,232,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,290,50,,232,percent of total billed charges,50% of total billed charges,185.31,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,185.31,31.95,,148.248,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,220.4,38,,176.32,percent of total billed charges,38% of total billed charges,232,40,,185.6,percent of total billed charges,40% of total billed charges,6037.94,7689,
NAIL KIT 10MM X 420MML RIGHT 125DEG,4400769,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3500,2100,,3675,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1230.25,35.15,,984.2,percent of total billed charges,35.15% of total billed charges,16.82,31.95,,13.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1330,38,,1064,percent of total billed charges,38% of total billed charges,1118.25,31.95,,894.6,percent of total billed charges,31.95% of total billed charges,6038.94,7690,
BIOLOX CERAMIC V40 FEMORAL HEAD 36MM X -5MM,4400770,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6039.94,7691,
TRIATHLON ASYM. PATELLA A38,4400771,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6040.94,7692,
TRIATHLON CS TIBIAL INSERT 6 X 9MM,4400772,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6041.94,7693,
JURGAN YELLOW PIN BALL,4400773,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,6042.94,7694,
JURGAN GREEN PIN BALL,4400774,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,6043.94,7695,
JURGAN BLUE PIN BALL,4400775,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,6044.94,7696,
JURGAN CREAM PIN BALL,4400776,CDM,270,RC,,,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,15,50,,12,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,15,50,,12,percent of total billed charges,50% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,6045.94,7697,
SCREW 6.5MM DIA 80MML,4400777,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,460,276,,483,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,161.69,35.15,,129.352,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,174.8,38,,139.84,percent of total billed charges,38% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,6046.94,7698,
PLATE BONE 145 DEGREE 79MML HOLEX4 OMEGA3,4400778,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6047.94,7699,
95MM LAG SCREW,4400779,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,496,297.6,,520.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,174.34,35.15,,139.472,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,188.48,38,,150.784,percent of total billed charges,38% of total billed charges,158.47,31.95,,126.776,percent of total billed charges,31.95% of total billed charges,6048.94,7700,
SCREW 4.5MM DIA 40MML OMEGA3,4400780,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,6049.94,7701,
SCREW 4.5MM DIA 46MML OMEGA3,4400781,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,6.05,31.95,,4.84,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,6050.94,7702,
SCREW 4.5MM DIA 30MML OMEGA3,4400782,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,72,43.2,,75.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.31,35.15,,20.248,percent of total billed charges,35.15% of total billed charges,36.86,31.95,,29.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,18.4,percent of total billed charges,31.95% of total billed charges,6051.94,7703,
TRIATHLON TIBIAL PREP KIT SIZE 6 CR,4400783,CDM,272,RC,,,OUTPATIENT,,,380,228,,323,85,,258.4,Percent of total billed charges,85% of total billed charges,190,50,,152,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,190,50,,152,percent of total billed charges,50% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,121.41,31.95,,97.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,144.4,38,,115.52,percent of total billed charges,38% of total billed charges,152,40,,121.6,percent of total billed charges,40% of total billed charges,6052.94,7704,
2.0MM DIAMOND ROUND BUR,4400784,CDM,272,RC,,,OUTPATIENT,,,144,86.4,,122.4,85,,97.92,Percent of total billed charges,85% of total billed charges,72,50,,57.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,72,50,,57.6,percent of total billed charges,50% of total billed charges,46.01,31.95,,36.808,percent of total billed charges,31.95% of total billed charges,46.01,31.95,,36.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,54.72,38,,43.776,percent of total billed charges,38% of total billed charges,57.6,40,,46.08,percent of total billed charges,40% of total billed charges,6053.94,7705,
TRIATHLON RETAINING FEMORAL #6 LEFT,4400785,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,37.82,31.95,,30.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,6054.94,7706,
TRIATHLON TIBIAL TITANIUM #7,4400786,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,22.84,31.95,,18.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,6055.94,7707,
TRIATHLON TIBIAL INSERT #7 13MM,4400787,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,24.92,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6056.94,7708,
DBM BONE PUTTY,4400788,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1780,1068,,1869,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,625.67,35.15,,500.536,percent of total billed charges,35.15% of total billed charges,25.8,31.95,,20.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,676.4,38,,541.12,percent of total billed charges,38% of total billed charges,568.71,31.95,,454.968,percent of total billed charges,31.95% of total billed charges,6057.94,7709,
TRIATHLON TIBIAL INSERT- CS #7 11MM,4400789,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,8.91,31.95,,7.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6058.94,7710,
TRIATHLON RETAINING FEMORAL #6 RIGHT,4400790,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,17.51,31.95,,14.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6059.94,7711,
TRIATHLON ALL POLY TIBIAL CS #9 9MM,4400791,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,6060.94,7712,
TRIATHLON TS FEMUR #6 RIGHT,4400792,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,9092,5455.2,,9546.6,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3195.84,35.15,,2556.672,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3454.96,38,,2763.968,percent of total billed charges,38% of total billed charges,2904.89,31.95,,2323.912,percent of total billed charges,31.95% of total billed charges,6061.94,7713,
TRIATHLON TIBIAL CONE AUGMENT SZ C,4400793,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5800,3480,,6090,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2038.7,35.15,,1630.96,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2204,38,,1763.2,percent of total billed charges,38% of total billed charges,1853.1,31.95,,1482.48,percent of total billed charges,31.95% of total billed charges,6062.94,7714,
TRIATHLON TIBIAL AUGMENT #5 5MM,4400794,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1500,900,,1575,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,527.25,35.15,,421.8,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,570,38,,456,percent of total billed charges,38% of total billed charges,479.25,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,6063.94,7715,
TRIATHLON TIBIAL AUGMENT HALF BLOCK #5 5MM,4400795,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1500,900,,1575,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,527.25,35.15,,421.8,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,570,38,,456,percent of total billed charges,38% of total billed charges,479.25,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,6064.94,7716,
TRIATHLON X3 TS INSERT #5 22MM,4400796,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3325,1995,,3491.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1168.74,35.15,,934.992,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1263.5,38,,1010.8,percent of total billed charges,38% of total billed charges,1062.34,31.95,,849.872,percent of total billed charges,31.95% of total billed charges,6065.94,7717,
TRIATHLON FEMUR DISTAL AUGMENT RIGHT #6 5MM,4400797,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1564,938.4,,1642.2,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,549.75,35.15,,439.8,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,594.32,38,,475.456,percent of total billed charges,38% of total billed charges,499.7,31.95,,399.76,percent of total billed charges,31.95% of total billed charges,6066.94,7718,
TRIATHLON FLUTED STEM 21MM X 100MM,4400798,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1740,1044,,1827,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,611.61,35.15,,489.288,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,661.2,38,,528.96,percent of total billed charges,38% of total billed charges,555.93,31.95,,444.744,percent of total billed charges,31.95% of total billed charges,6067.94,7719,
TRIATHLON FLUTED STEM 17MM X 100MM,4400799,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1740,1044,,1827,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,611.61,35.15,,489.288,percent of total billed charges,35.15% of total billed charges,4.58,31.95,,3.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,661.2,38,,528.96,percent of total billed charges,38% of total billed charges,555.93,31.95,,444.744,percent of total billed charges,31.95% of total billed charges,6068.94,7720,
STRAIGHT OSTEOTOME 6.4MM X 120MM,4400800,CDM,270,RC,,,OUTPATIENT,,,375,225,,318.75,85,,255,Percent of total billed charges,85% of total billed charges,187.5,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,187.5,50,,150,percent of total billed charges,50% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,142.5,38,,114,percent of total billed charges,38% of total billed charges,150,40,,120,percent of total billed charges,40% of total billed charges,6069.94,7721,
TRIATHLON TRITANIUM TIBIAL #2,4400801,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,9.72,31.95,,7.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,6070.94,7722,
TRIATHLON X3 TIBIAL BEARING INSERT-CS #2 11MM,4400802,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,11.53,31.95,,9.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6071.94,7723,
TRIATHLON X3 TIBIAL BEARING INSERT-CS SZ 7 16MM,4400803,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.99,31.95,,3.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6072.94,7724,
ACCOLADE II STEM 127 DEGREE SZ 7 37MM 114MM V40,4400804,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,4.46,31.95,,3.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6073.94,7725,
CLAVICLE PLATE 122MML RIGHT LATERAL SUPERIOR CLAVICLE,4400805,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2598,1558.8,,2727.9,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,913.2,35.15,,730.56,percent of total billed charges,35.15% of total billed charges,4.98,31.95,,3.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,987.24,38,,789.792,percent of total billed charges,38% of total billed charges,830.06,31.95,,664.048,percent of total billed charges,31.95% of total billed charges,6074.94,7726,
3.0 CANNULATED SCREW 40MM,4400806,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,31.8,31.95,,25.44,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,6075.94,7727,
ACCOLADE II HIP STEM #3,4400807,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,5.19,31.95,,4.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6076.94,7728,
LONG K-WIRE 0.062,4400808,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,115,69,,120.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.42,35.15,,32.336,percent of total billed charges,35.15% of total billed charges,6.23,31.95,,4.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,6077.94,7729,
ACCOLADE II 127 DEGREE NECK ANGLE HIP STEM #6 35MM,4400809,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,6.26,31.95,,5.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6078.94,7730,
BIOLOX DELTA CERAMIC V40 FOMERAL HEAL 36MM -2.5MM,4400810,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,6.32,31.95,,5.056,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6079.94,7731,
GRAVITY SYNCHFIX SUTURE #5,4400811,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2300,1380,,2415,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,808.45,35.15,,646.76,percent of total billed charges,35.15% of total billed charges,6.33,31.95,,5.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,874,38,,699.2,percent of total billed charges,38% of total billed charges,734.85,31.95,,587.88,percent of total billed charges,31.95% of total billed charges,6080.94,7732,
ACCOLADE II HIP STEM 132 DEGREE #2,4400812,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,8.83,31.95,,7.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6081.94,7733,
TRIATHLON CR PF FEMUR #2 LT,4400813,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,8.83,31.95,,7.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,6082.94,7734,
TRIATHLON X3 BEARING INSERT #2 X 9MM,4400814,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6083.94,7735,
PLATE HOLE 3 LEFT PROXIMAL LATERAL HUMERAL,4400815,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3130,1878,,3286.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1100.2,35.15,,880.16,percent of total billed charges,35.15% of total billed charges,4.28,31.95,,3.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1189.4,38,,951.52,percent of total billed charges,38% of total billed charges,1000.04,31.95,,800.032,percent of total billed charges,31.95% of total billed charges,6084.94,7736,
3.5MM SCREW CORTICAL 26MM,4400816,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,80,48,,84,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.12,35.15,,22.496,percent of total billed charges,35.15% of total billed charges,6.42,31.95,,5.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,6085.94,7737,
3.5MM SCREW CORTICAL 28MM,4400817,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,80,48,,84,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.12,35.15,,22.496,percent of total billed charges,35.15% of total billed charges,7.1,31.95,,5.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,6086.94,7738,
4.0 LOCK SCREW 24MM,4400818,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,389,233.4,,408.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,136.73,35.15,,109.384,percent of total billed charges,35.15% of total billed charges,8.6,31.95,,6.88,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.82,38,,118.256,percent of total billed charges,38% of total billed charges,124.29,31.95,,99.432,percent of total billed charges,31.95% of total billed charges,6087.94,7739,
4.0 CANCELLOUS SCREW 44MM,4400819,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,88,52.8,,92.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,30.93,35.15,,24.744,percent of total billed charges,35.15% of total billed charges,10.43,31.95,,8.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,33.44,38,,26.752,percent of total billed charges,38% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,6088.94,7740,
TRIDENT II MULTIHOLE SHELL 36MM,4400820,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4570,2742,,4798.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1606.36,35.15,,1285.088,percent of total billed charges,35.15% of total billed charges,10.75,31.95,,8.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1736.6,38,,1389.28,percent of total billed charges,38% of total billed charges,1460.12,31.95,,1168.096,percent of total billed charges,31.95% of total billed charges,6089.94,7741,
MDM LINER-CEMENTLESS,4400821,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2030,1218,,2131.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,713.55,35.15,,570.84,percent of total billed charges,35.15% of total billed charges,11.53,31.95,,9.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,771.4,38,,617.12,percent of total billed charges,38% of total billed charges,648.59,31.95,,518.872,percent of total billed charges,31.95% of total billed charges,6090.94,7742,
MDM INSERT,4400822,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1600,960,,1680,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,562.4,35.15,,449.92,percent of total billed charges,35.15% of total billed charges,11.53,31.95,,9.224,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,608,38,,486.4,percent of total billed charges,38% of total billed charges,511.2,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,6091.94,7743,
TRIDENT X3 INSERT 32MM,4400823,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,11.78,31.95,,9.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6092.94,7744,
BIOLOX DELTA CERAMIC HEAD 32MM X +0MM,4400824,CDM,270,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1402.5,85,,1122,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,13.71,31.95,,10.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6093.94,7745,
TRIDENT X3 10 DEGREE INSERT 36MM,4400825,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,15.06,31.95,,12.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6094.94,7746,
TRIATHLON CR FEMORAL #2 LEFT,4400826,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,15.06,31.95,,12.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6095.94,7747,
TRIATHLON X3 CS INSERT #2 19MM,4400827,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,15.1,31.95,,12.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6096.94,7748,
TRIATHLON CEMENTED STEM 9MM X 100MM,4400828,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,17.28,31.95,,13.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6097.94,7749,
REUNION PF STEM 14MM,4400829,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5500,3300,,5775,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1933.25,35.15,,1546.6,percent of total billed charges,35.15% of total billed charges,17.28,31.95,,13.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2090,38,,1672,percent of total billed charges,38% of total billed charges,1757.25,31.95,,1405.8,percent of total billed charges,31.95% of total billed charges,6098.94,7750,
MDM LINER 38D 38MM,4400830,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2030,1218,,2131.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,713.55,35.15,,570.84,percent of total billed charges,35.15% of total billed charges,17.28,31.95,,13.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,771.4,38,,617.12,percent of total billed charges,38% of total billed charges,648.59,31.95,,518.872,percent of total billed charges,31.95% of total billed charges,6099.94,7751,
MDM INSERT X3 38D,4400831,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1600,960,,1680,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,562.4,35.15,,449.92,percent of total billed charges,35.15% of total billed charges,17.83,31.95,,14.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,608,38,,486.4,percent of total billed charges,38% of total billed charges,511.2,31.95,,408.96,percent of total billed charges,31.95% of total billed charges,6100.94,7752,
C TAPER LFIT HEAD 22MM + 5,4400832,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,18.28,31.95,,14.624,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6101.94,7753,
OMNIFIT EON STEM #5 132 DEGREE,4400833,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6102.94,7754,
OMNIFIT DISTAL CEMENT SPACER 12MM,4400834,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,200,120,,210,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,56.24,percent of total billed charges,35.15% of total billed charges,19.44,31.95,,15.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,60.8,percent of total billed charges,38% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,6103.94,7755,
TRIATHLON X3 CS INSERT #3 9MM,4400835,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,21.88,31.95,,17.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6104.94,7756,
BIOLOX CERAMIC HEAD 36MM +5MM,4400836,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,22.59,31.95,,18.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6105.94,7757,
ACCOLADE II HIP STEM #8 127 DEGREE,4400837,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,22.59,31.95,,18.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6106.94,7758,
TRIATHLON X3 TIBIAL INSERT CS #4 13MM,4400838,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,22.59,31.95,,18.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6107.94,7759,
DRILL,4400839,CDM,270,RC,,,OUTPATIENT,,,535,321,,454.75,85,,363.8,Percent of total billed charges,85% of total billed charges,267.5,50,,214,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,267.5,50,,214,percent of total billed charges,50% of total billed charges,170.93,31.95,,136.744,percent of total billed charges,31.95% of total billed charges,170.93,31.95,,136.744,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,203.3,38,,162.64,percent of total billed charges,38% of total billed charges,214,40,,171.2,percent of total billed charges,40% of total billed charges,6108.94,7760,
8 X 8 X 8 EASY CLIP,4400840,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,24.76,31.95,,19.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,6109.94,7761,
52MM X ID 36MM EXETER CUP,4400841,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2705,1623,,2840.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,950.81,35.15,,760.648,percent of total billed charges,35.15% of total billed charges,28.61,31.95,,22.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1027.9,38,,822.32,percent of total billed charges,38% of total billed charges,864.25,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,6110.94,7762,
44 OFFSET NO 1 EXETER STEM,4400842,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,28.61,31.95,,22.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6111.94,7763,
36MM 0MM V40 HEAD,4400843,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,27.19,31.95,,21.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6112.94,7764,
EXETER X3 RIMFIT CUP (46/28),4400844,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2705,1623,,2840.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,950.81,35.15,,760.648,percent of total billed charges,35.15% of total billed charges,29.88,31.95,,23.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1027.9,38,,822.32,percent of total billed charges,38% of total billed charges,864.25,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,6113.94,7765,
EXETER X3 RIMFIT CUP (50/32),4400845,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2705,1623,,2840.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,950.81,35.15,,760.648,percent of total billed charges,35.15% of total billed charges,4.49,31.95,,3.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1027.9,38,,822.32,percent of total billed charges,38% of total billed charges,864.25,31.95,,691.4,percent of total billed charges,31.95% of total billed charges,6114.94,7766,
LFIT V40 FEMORAL HEAD (28+8),4400846,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,73.26,31.95,,58.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6115.94,7767,
UH1 BIPOLAR HEAD #51,4400847,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1350,810,,1417.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,474.53,35.15,,379.624,percent of total billed charges,35.15% of total billed charges,75.17,31.95,,60.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,513,38,,410.4,percent of total billed charges,38% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,6116.94,7768,
C TAPER LFIT HEAD #28+5,4400848,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,87.25,31.95,,69.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6117.94,7769,
OMNIFIT ECON STEM # 8/127 DEGREE,4400849,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,167.92,31.95,,134.336,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6118.94,7770,
TRIATHLON X3 TIBIA POLY INSERT #4 X 19,4400850,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,174.91,31.95,,139.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6119.94,7771,
CELLERATE RX 1G SURGICAL POWDER,4400851,CDM,270,RC,,,OUTPATIENT,,,740,444,,629,85,,503.2,Percent of total billed charges,85% of total billed charges,370,50,,296,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,370,50,,296,percent of total billed charges,50% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,236.43,31.95,,189.144,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,281.2,38,,224.96,percent of total billed charges,38% of total billed charges,296,40,,236.8,percent of total billed charges,40% of total billed charges,6120.94,7772,
CELLERATE RX 5G SURGICAL POWDER,4400852,CDM,270,RC,,,OUTPATIENT,,,2240,1344,,1904,85,,1523.2,Percent of total billed charges,85% of total billed charges,1120,50,,896,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,1120,50,,896,percent of total billed charges,50% of total billed charges,715.68,31.95,,572.544,percent of total billed charges,31.95% of total billed charges,715.68,31.95,,572.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,851.2,38,,680.96,percent of total billed charges,38% of total billed charges,896,40,,716.8,percent of total billed charges,40% of total billed charges,6121.94,7773,
TRIATHLON X3 CS INSERT # 2 11MM,4400853,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,41.24,31.95,,32.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6122.94,7774,
BIT DRILL 2MM DIA AO SHAFT CALIBRATED F/EASYCLIP SUPERELASTI,4400854,CDM,270,RC,,,OUTPATIENT,,,400,240,,340,85,,272,Percent of total billed charges,85% of total billed charges,200,50,,160,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,200,50,,160,percent of total billed charges,50% of total billed charges,127.8,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,127.8,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,152,38,,121.6,percent of total billed charges,38% of total billed charges,160,40,,128,percent of total billed charges,40% of total billed charges,6123.94,7775,
STAPLE BONE FIXATION 12 X 10 X 10 EASYCLIP,4400855,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,34.76,31.95,,27.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,6124.94,7776,
OMNIFIT EON #4 STEM 25MM 100MM,4400856,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,34.89,31.95,,27.912,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6125.94,7777,
C TAPER LFIT FEMORAL HEAL 36MM,4400857,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6126.94,7778,
ACCOLADE II STEM 127 DEGREE #1,4400858,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,38.94,31.95,,31.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6127.94,7779,
TRIATHLON X3 TIBIAL INSERT #4 X 11MM,4400860,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,38.94,31.95,,31.152,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6128.94,7780,
TRIATHLON RETAINING FEMORAL #7 LT,4400862,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,5.39,31.95,,4.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,6129.94,7781,
TRIATHLON X3 TIBIAL INSERT #7 9MM,4400863,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,6.92,31.95,,5.536,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6130.94,7782,
2.5CC VITOSS,4400864,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1795,1077,,1884.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,630.94,35.15,,504.752,percent of total billed charges,35.15% of total billed charges,7.24,31.95,,5.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,682.1,38,,545.68,percent of total billed charges,38% of total billed charges,573.5,31.95,,458.8,percent of total billed charges,31.95% of total billed charges,6131.94,7783,
3.5MM SCREW CORTICAL 32MM,4400865,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,80,48,,84,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.12,35.15,,22.496,percent of total billed charges,35.15% of total billed charges,7.48,31.95,,5.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,6132.94,7784,
ACTICOAT FLEX 7 SILVER DRESSING,4400866,CDM,270,RC,,,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,22.5,50,,18,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,22.5,50,,18,percent of total billed charges,50% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,18,40,,14.4,percent of total billed charges,40% of total billed charges,6133.94,7785,
PICO 14 NEGATIVE PRESSURE WOUND THERAPY SYSTEM,4400867,CDM,272,RC,A9272,HCPCS,OUTPATIENT,,,437,262.2,,371.45,85,,297.16,Percent of total billed charges,85% of total billed charges,218.5,50,,174.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,218.5,50,,174.8,percent of total billed charges,50% of total billed charges,153.61,35.15,,122.888,percent of total billed charges,35.15% of total billed charges,26.64,31.95,,21.312,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,166.06,38,,132.848,percent of total billed charges,38% of total billed charges,139.62,31.95,,111.696,percent of total billed charges,31.95% of total billed charges,6134.94,7786,
OVERDRILL 3.5,4400868,CDM,270,RC,,,OUTPATIENT,,,388,232.8,,329.8,85,,263.84,Percent of total billed charges,85% of total billed charges,194,50,,155.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,194,50,,155.2,percent of total billed charges,50% of total billed charges,123.97,31.95,,99.176,percent of total billed charges,31.95% of total billed charges,123.97,31.95,,99.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,147.44,38,,117.952,percent of total billed charges,38% of total billed charges,155.2,40,,124.16,percent of total billed charges,40% of total billed charges,6135.94,7787,
TAP 3.5,4400869,CDM,270,RC,,,OUTPATIENT,,,910,546,,773.5,85,,618.8,Percent of total billed charges,85% of total billed charges,455,50,,364,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,455,50,,364,percent of total billed charges,50% of total billed charges,290.75,31.95,,232.6,percent of total billed charges,31.95% of total billed charges,290.75,31.95,,232.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,345.8,38,,276.64,percent of total billed charges,38% of total billed charges,364,40,,291.2,percent of total billed charges,40% of total billed charges,6136.94,7788,
PROXIMAL LATERAL HUMERUS PLATE RIGHT 16 HOLE/L254MM,4400870,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4020,2412,,4221,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1413.03,35.15,,1130.424,percent of total billed charges,35.15% of total billed charges,26.91,31.95,,21.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1527.6,38,,1222.08,percent of total billed charges,38% of total billed charges,1284.39,31.95,,1027.512,percent of total billed charges,31.95% of total billed charges,6137.94,7789,
6.5MM CANCELLOUS TI SCREW 25MM,4400871,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,180,108,,189,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,50.616,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,68.4,38,,54.72,percent of total billed charges,38% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,6138.94,7790,
3.5MM CORTICAL SCREW 22MM,4400872,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,140,84,,147,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.21,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,6139.94,7791,
3.5MM CORTICAL SCREW 30MM,4400873,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,140,84,,147,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.21,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,6140.94,7792,
4.0 LOCK SCREW 14MM,4400874,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,290,174,,304.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,101.94,35.15,,81.552,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.2,38,,88.16,percent of total billed charges,38% of total billed charges,92.66,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,6141.94,7793,
TRIDENT X3 INSERT #32/10 DEGREE,4400875,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,108.03,31.95,,86.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6142.94,7794,
4.0 CANN SCREW 26MM,4400876,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,397,238.2,,416.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,139.55,35.15,,111.64,percent of total billed charges,35.15% of total billed charges,112.53,31.95,,90.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.86,38,,120.688,percent of total billed charges,38% of total billed charges,126.84,31.95,,101.472,percent of total billed charges,31.95% of total billed charges,6143.94,7795,
K-WIRE UNTHREADED ASNIS,4400877,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,220,132,,231,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,77.33,35.15,,61.864,percent of total billed charges,35.15% of total billed charges,523.09,31.95,,418.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,83.6,38,,66.88,percent of total billed charges,38% of total billed charges,70.29,31.95,,56.232,percent of total billed charges,31.95% of total billed charges,6144.94,7796,
CANN SCREW 4.0MM/L60MM,4400879,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1802,1081.2,,1892.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,633.4,35.15,,506.72,percent of total billed charges,35.15% of total billed charges,610.53,31.95,,488.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684.76,38,,547.808,percent of total billed charges,38% of total billed charges,575.74,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,6145.94,7797,
CANN SCREW 4.0MM/L50MM,4400880,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1802,1081.2,,1892.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,633.4,35.15,,506.72,percent of total billed charges,35.15% of total billed charges,35.16,31.95,,28.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684.76,38,,547.808,percent of total billed charges,38% of total billed charges,575.74,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,6146.94,7798,
CANN SCREW 4.0MM/L42MM,4400881,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1802,1081.2,,1892.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,633.4,35.15,,506.72,percent of total billed charges,35.15% of total billed charges,39.25,31.95,,31.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684.76,38,,547.808,percent of total billed charges,38% of total billed charges,575.74,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,6147.94,7799,
CAMERA DRAPE,4400882,CDM,270,RC,,,OUTPATIENT,,,26,15.6,,22.1,85,,17.68,Percent of total billed charges,85% of total billed charges,13,50,,10.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,13,50,,10.4,percent of total billed charges,50% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,8.31,31.95,,6.648,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,9.88,38,,7.904,percent of total billed charges,38% of total billed charges,10.4,40,,8.32,percent of total billed charges,40% of total billed charges,6148.94,7800,
WASHER SPIKED,4400883,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,150,90,,157.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,42.184,percent of total billed charges,35.15% of total billed charges,35.95,31.95,,28.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,6149.94,7801,
6.0 CANN SCREW 60MM,4400884,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,54.33,31.95,,43.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,6150.94,7802,
ACCOLADE II HIP STEM #5,4400885,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,74.02,31.95,,59.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6151.94,7803,
RASP HELIOCOIDAL 3.2MM X 18.3MM,4400886,CDM,270,RC,,,OUTPATIENT,,,210,126,,178.5,85,,142.8,Percent of total billed charges,85% of total billed charges,105,50,,84,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,105,50,,84,percent of total billed charges,50% of total billed charges,67.1,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,67.1,31.95,,53.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,79.8,38,,63.84,percent of total billed charges,38% of total billed charges,84,40,,67.2,percent of total billed charges,40% of total billed charges,6152.94,7804,
KWIRE 1.8 X 310,4400889,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,244,146.4,,256.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,85.77,35.15,,68.616,percent of total billed charges,35.15% of total billed charges,11.21,31.95,,8.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,92.72,38,,74.176,percent of total billed charges,38% of total billed charges,77.96,31.95,,62.368,percent of total billed charges,31.95% of total billed charges,6153.94,7805,
NAIL CANNULATED 11MM X 380MML STERILE,4400890,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3090,1854,,3244.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1086.14,35.15,,868.912,percent of total billed charges,35.15% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1174.2,38,,939.36,percent of total billed charges,38% of total billed charges,987.26,31.95,,789.808,percent of total billed charges,31.95% of total billed charges,6154.94,7806,
SCREW LOCKING 5MM X 80MML FEMORAL,4400891,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,111.51,31.95,,89.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6155.94,7807,
SCREW CANN LOCKING 5MM X 85MML FEMORAL,4400892,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,320,192,,336,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.48,35.15,,89.984,percent of total billed charges,35.15% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.6,38,,97.28,percent of total billed charges,38% of total billed charges,102.24,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,6156.94,7808,
NUT CONDYLE 5MM,4400893,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,320,192,,336,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.48,35.15,,89.984,percent of total billed charges,35.15% of total billed charges,63.99,31.95,,51.192,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.6,38,,97.28,percent of total billed charges,38% of total billed charges,102.24,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,6157.94,7809,
END CAP 8MM,4400894,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,7.5,31.95,,6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,6158.94,7810,
TRIATHLON TIBIAL INSERT SZ 3 X 16MM,4400895,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,7.76,31.95,,6.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6159.94,7811,
CENTER SCREW,4400896,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,200,120,,210,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,56.24,percent of total billed charges,35.15% of total billed charges,8.2,31.95,,6.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,60.8,percent of total billed charges,38% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,6160.94,7812,
STEM,4400897,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5550,3330,,5827.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1950.83,35.15,,1560.664,percent of total billed charges,35.15% of total billed charges,80.26,31.95,,64.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2109,38,,1687.2,percent of total billed charges,38% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,6161.94,7813,
INSERT,4400898,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,103.56,31.95,,82.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,6162.94,7814,
DRILL 3.5 X 230MM,4400899,CDM,270,RC,,,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,175,50,,140,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,175,50,,140,percent of total billed charges,50% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,140,40,,112,percent of total billed charges,40% of total billed charges,6163.94,7815,
DRILL 3.5 X 130MM,4400900,CDM,270,RC,,,OUTPATIENT,,,350,210,,297.5,85,,238,Percent of total billed charges,85% of total billed charges,175,50,,140,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,175,50,,140,percent of total billed charges,50% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,133,38,,106.4,percent of total billed charges,38% of total billed charges,140,40,,112,percent of total billed charges,40% of total billed charges,6164.94,7816,
GUIDEWIRE 2.2 X 800MM,4400901,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,338,202.8,,354.9,105,,,case rate,pays based on 105% of threshold rate,169,50,,135.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,169,50,,135.2,percent of total billed charges,50% of total billed charges,118.81,35.15,,95.048,percent of total billed charges,35.15% of total billed charges,12.07,31.95,,9.656,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,128.44,38,,102.752,percent of total billed charges,38% of total billed charges,107.99,31.95,,86.392,percent of total billed charges,31.95% of total billed charges,6165.94,7817,
9 X 250MM HUMERAL NAIL,4400902,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2329,1397.4,,2445.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,818.64,35.15,,654.912,percent of total billed charges,35.15% of total billed charges,28.81,31.95,,23.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,885.02,38,,708.016,percent of total billed charges,38% of total billed charges,744.12,31.95,,595.296,percent of total billed charges,31.95% of total billed charges,6166.94,7818,
4 X 50MM LOCKING SCREW,4400903,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,2751.04,31.95,,2200.832,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,6167.94,7819,
4 X 40MM LOCKING SCREW,4400904,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,10965.69,31.95,,8772.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,6168.94,7820,
4 X 30MM LOCKING SCREW,4400905,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,209.28,31.95,,167.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,6169.94,7821,
4 X 45MM LOCKING SCREW,4400906,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,6170.94,7822,
6.0 CANN SCREW 65MM,4400907,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,6171.94,7823,
RFX HUMERAL CUP SPACE ADAPTOR,4400908,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,402,241.2,,422.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,141.3,35.15,,113.04,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,152.76,38,,122.208,percent of total billed charges,38% of total billed charges,128.44,31.95,,102.752,percent of total billed charges,31.95% of total billed charges,6172.94,7824,
CENTRAL SCREW 6.5 X 32MM,4400909,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,150,90,,157.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,42.184,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,6173.94,7825,
PERIPHERAL SCREW 4.5 X 28,4400910,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,150,90,,157.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,42.184,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,6174.94,7826,
FX STEM 10,4400911,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5550,3330,,5827.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1950.83,35.15,,1560.664,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2109,38,,1687.2,percent of total billed charges,38% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,6175.94,7827,
INSERT 36 #4,4400912,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,6176.94,7828,
DRILL 1.6MM L96MM,4400913,CDM,270,RC,,,OUTPATIENT,,,340,204,,289,85,,231.2,Percent of total billed charges,85% of total billed charges,170,50,,136,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,170,50,,136,percent of total billed charges,50% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.2,38,,103.36,percent of total billed charges,38% of total billed charges,136,40,,108.8,percent of total billed charges,40% of total billed charges,6177.94,7829,
T-PLATE 2.0 L62MM 5X10 HOLES,4400914,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1285,771,,1349.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,451.68,35.15,,361.344,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,488.3,38,,390.64,percent of total billed charges,38% of total billed charges,410.56,31.95,,328.448,percent of total billed charges,31.95% of total billed charges,6178.94,7830,
2.0 LOCK SCREW 12MM,4400915,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,345,207,,362.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,121.27,35.15,,97.016,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.1,38,,104.88,percent of total billed charges,38% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,6179.94,7831,
2.0 LOCK SCREW 14MM,4400916,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,345,207,,362.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,121.27,35.15,,97.016,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.1,38,,104.88,percent of total billed charges,38% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,6180.94,7832,
2.0 LOCK SCREW 16MM,4400917,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,345,207,,362.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,121.27,35.15,,97.016,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.1,38,,104.88,percent of total billed charges,38% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,6181.94,7833,
2.0 LOCK SCREW 18MM,4400918,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,345,207,,362.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,121.27,35.15,,97.016,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.1,38,,104.88,percent of total billed charges,38% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,6182.94,7834,
180MM 5MM AO QUICK COUPLING DRILL NONSTERILE,4400919,CDM,270,RC,,,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75,50,,60,percent of total billed charges,50% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,60,40,,48,percent of total billed charges,40% of total billed charges,6183.94,7835,
180MM 3.2MM AO QUICK COUPLING DRILL NONSTERILE,4400920,CDM,270,RC,,,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,75,50,,60,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75,50,,60,percent of total billed charges,50% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,60,40,,48,percent of total billed charges,40% of total billed charges,6184.94,7836,
4MM X 450MM T2 KIDS PEDIATRIC FLEXIBLE NAIL STERILE,4400921,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,475,285,,498.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,166.96,35.15,,133.568,percent of total billed charges,35.15% of total billed charges,88.26,31.95,,70.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,180.5,38,,144.4,percent of total billed charges,38% of total billed charges,151.76,31.95,,121.408,percent of total billed charges,31.95% of total billed charges,6185.94,7837,
3MM X 450MM T2 KIDS PEDIATRIC FLEXIBLE NAIL STERILE,4400922,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,450,270,,472.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,126.544,percent of total billed charges,35.15% of total billed charges,88.26,31.95,,70.608,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,171,38,,136.8,percent of total billed charges,38% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,6186.94,7838,
ULNA LOCK T-PLATE 2.4 L41MM 2X5 HOLES,4400923,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1500,900,,1575,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,527.25,35.15,,421.8,percent of total billed charges,35.15% of total billed charges,183.02,31.95,,146.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,570,38,,456,percent of total billed charges,38% of total billed charges,479.25,31.95,,383.4,percent of total billed charges,31.95% of total billed charges,6187.94,7839,
2.4 LOCKING SCREW 7MM,4400924,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,345,207,,362.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,121.27,35.15,,97.016,percent of total billed charges,35.15% of total billed charges,29.91,31.95,,23.928,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,131.1,38,,104.88,percent of total billed charges,38% of total billed charges,110.23,31.95,,88.184,percent of total billed charges,31.95% of total billed charges,6188.94,7840,
UHR HEAD BIPOLAR COMPONENT 45MM X 28MM,4400925,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1350,810,,1417.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,474.53,35.15,,379.624,percent of total billed charges,35.15% of total billed charges,4355.25,31.95,,3484.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,513,38,,410.4,percent of total billed charges,38% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,6189.94,7841,
POST 30 DEGREE 11MM DIA,4400926,CDM,272,RC,,,OUTPATIENT,,,915,549,,777.75,85,,622.2,Percent of total billed charges,85% of total billed charges,457.5,50,,366,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,457.5,50,,366,percent of total billed charges,50% of total billed charges,292.34,31.95,,233.872,percent of total billed charges,31.95% of total billed charges,292.34,31.95,,233.872,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,347.7,38,,278.16,percent of total billed charges,38% of total billed charges,366,40,,292.8,percent of total billed charges,40% of total billed charges,6190.94,7842,
ROD EXTERNAL 8MM DIA 150MM,4400927,CDM,272,RC,,,OUTPATIENT,,,470,282,,399.5,85,,319.6,Percent of total billed charges,85% of total billed charges,235,50,,188,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,235,50,,188,percent of total billed charges,50% of total billed charges,150.17,31.95,,120.136,percent of total billed charges,31.95% of total billed charges,150.17,31.95,,120.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,178.6,38,,142.88,percent of total billed charges,38% of total billed charges,188,40,,150.4,percent of total billed charges,40% of total billed charges,6191.94,7843,
OMEGA PLATE 130 DEGREE,4400928,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,975,585,,1023.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,342.71,35.15,,274.168,percent of total billed charges,35.15% of total billed charges,4.98,31.95,,3.984,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,370.5,38,,296.4,percent of total billed charges,38% of total billed charges,311.51,31.95,,249.208,percent of total billed charges,31.95% of total billed charges,6192.94,7844,
LAG SCREW TAP LARGE AO FITTING OMEGA3,4400929,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,340,204,,357,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,119.51,35.15,,95.608,percent of total billed charges,35.15% of total billed charges,22.42,31.95,,17.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.2,38,,103.36,percent of total billed charges,38% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,6193.94,7845,
SCREW 4.5MM DIA 42MM OMEGA3 NON-STERILE,4400930,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,55,33,,57.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.33,35.15,,15.464,percent of total billed charges,35.15% of total billed charges,36,31.95,,28.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,20.9,38,,16.72,percent of total billed charges,38% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,6194.94,7846,
TRIATHLON CR FEMUR #8,4400931,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,7.64,31.95,,6.112,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,6195.94,7847,
TRIATHLON X3 CS INSERT 8 X 11MML,4400933,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,8.07,31.95,,6.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6196.94,7848,
TRIATHLON X3 ASYMMETRIC PATELLA 11MM,4400934,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,8.22,31.95,,6.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6197.94,7849,
TRIATHLON TIBIA #8,4400935,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,8.84,31.95,,7.072,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,6198.94,7850,
TRIATHLON CR FEMORAL #6 LFT,4400936,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4050,2430,,4252.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1423.58,35.15,,1138.864,percent of total billed charges,35.15% of total billed charges,11.66,31.95,,9.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1539,38,,1231.2,percent of total billed charges,38% of total billed charges,1293.98,31.95,,1035.184,percent of total billed charges,31.95% of total billed charges,6199.94,7851,
OMEGA PLUS T-HANDLE QUICK COUPLING,4400937,CDM,272,RC,,,OUTPATIENT,,,1060,636,,901,85,,720.8,Percent of total billed charges,85% of total billed charges,530,50,,424,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,530,50,,424,percent of total billed charges,50% of total billed charges,338.67,31.95,,270.936,percent of total billed charges,31.95% of total billed charges,338.67,31.95,,270.936,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,402.8,38,,322.24,percent of total billed charges,38% of total billed charges,424,40,,339.2,percent of total billed charges,40% of total billed charges,6200.94,7852,
TRIATHLON TIBIAL INSERT CS #7-9MM,4400938,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6201.94,7853,
6.5 CANNULATED SCREW 100MM,4400939,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,460,276,,483,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,161.69,35.15,,129.352,percent of total billed charges,35.15% of total billed charges,3.95,31.95,,3.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,174.8,38,,139.84,percent of total billed charges,38% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,6202.94,7854,
PLATE LOCKING 79MML HOLEX4 135DEG HIP,4400940,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,460,276,,483,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,161.69,35.15,,129.352,percent of total billed charges,35.15% of total billed charges,13.24,31.95,,10.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,174.8,38,,139.84,percent of total billed charges,38% of total billed charges,146.97,31.95,,117.576,percent of total billed charges,31.95% of total billed charges,6203.94,7855,
3.5 LOCKING SCREW 80MM,4400941,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,140,84,,147,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.21,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,11.08,31.95,,8.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,6204.94,7856,
4.0 LOCKING SCREW 55MM,4400942,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,12.4,31.95,,9.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6205.94,7857,
4.0 LOCKING SCREW 65MM,4400943,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,12.4,31.95,,9.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6206.94,7858,
4.0 LOCKING SCREW 90MM,4400944,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,12.4,31.95,,9.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6207.94,7859,
4.0 LOCKING SCREW 95MM,4400945,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,12.91,31.95,,10.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6208.94,7860,
CANNULATED COMPRESSION SCREW 5.0MM/L38MM,4400946,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1802,1081.2,,1892.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,633.4,35.15,,506.72,percent of total billed charges,35.15% of total billed charges,4.01,31.95,,3.208,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684.76,38,,547.808,percent of total billed charges,38% of total billed charges,575.74,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,6209.94,7861,
CANNULATED COMPRESSION SCREW 5.0MM/L40MM,4400947,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1802,1081.2,,1892.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,633.4,35.15,,506.72,percent of total billed charges,35.15% of total billed charges,4.24,31.95,,3.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684.76,38,,547.808,percent of total billed charges,38% of total billed charges,575.74,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,6210.94,7862,
TRIDENT X3 10 DEGREE INSERT 36MM ALPHA F,4400948,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,4.62,31.95,,3.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6211.94,7863,
REAMER SHAFT,4400949,CDM,272,RC,,,OUTPATIENT,,,1029,617.4,,874.65,85,,699.72,Percent of total billed charges,85% of total billed charges,514.5,50,,411.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,514.5,50,,411.6,percent of total billed charges,50% of total billed charges,328.77,31.95,,263.016,percent of total billed charges,31.95% of total billed charges,328.77,31.95,,263.016,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,391.02,38,,312.816,percent of total billed charges,38% of total billed charges,411.6,40,,329.28,percent of total billed charges,40% of total billed charges,6212.94,7864,
NAIL INTRAMEDULLARY 10MM DIA 740MML T2,4400950,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,10158,6094.8,,10665.9,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3570.54,35.15,,2856.432,percent of total billed charges,35.15% of total billed charges,4.62,31.95,,3.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3860.04,38,,3088.032,percent of total billed charges,38% of total billed charges,3245.48,31.95,,2596.384,percent of total billed charges,31.95% of total billed charges,6213.94,7865,
UHR HEAD BIPOLAR COMPONENT 47MM X 28MM,4400951,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1350,810,,1417.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,474.53,35.15,,379.624,percent of total billed charges,35.15% of total billed charges,8.61,31.95,,6.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,513,38,,410.4,percent of total billed charges,38% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,6214.94,7866,
TRIATHION X3 TIBIAL INSERT-CB #2 13MM,4400952,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,9.08,31.95,,7.264,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6215.94,7867,
4.2 X 360M DRILL,4400953,CDM,270,RC,,,OUTPATIENT,,,411,246.6,,349.35,85,,279.48,Percent of total billed charges,85% of total billed charges,205.5,50,,164.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,205.5,50,,164.4,percent of total billed charges,50% of total billed charges,131.31,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,131.31,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,156.18,38,,124.944,percent of total billed charges,38% of total billed charges,164.4,40,,131.52,percent of total billed charges,40% of total billed charges,6216.94,7868,
8-13 INSERTION SLEEVE,4400954,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,258,154.8,,270.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,90.69,35.15,,72.552,percent of total billed charges,35.15% of total billed charges,44.86,31.95,,35.888,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,98.04,38,,78.432,percent of total billed charges,38% of total billed charges,82.43,31.95,,65.944,percent of total billed charges,31.95% of total billed charges,6217.94,7869,
9 X 315M TIBIAL NAIL,4400955,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2810,1686,,2950.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,987.72,35.15,,790.176,percent of total billed charges,35.15% of total billed charges,53.29,31.95,,42.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1067.8,38,,854.24,percent of total billed charges,38% of total billed charges,897.8,31.95,,718.24,percent of total billed charges,31.95% of total billed charges,6218.94,7870,
5 X 35M LOCKING SCREW,4400956,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,61.01,31.95,,48.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6219.94,7871,
5 X 37.5M LOCKING SCREW,4400957,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6220.94,7872,
5 X 45M LOCKING SCREW,4400958,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6221.94,7873,
5 X 65M LOCKING SCREW,4400959,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6222.94,7874,
5.0 CANN SCREW 42M,4400960,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1802,1081.2,,1892.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,633.4,35.15,,506.72,percent of total billed charges,35.15% of total billed charges,4.72,31.95,,3.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684.76,38,,547.808,percent of total billed charges,38% of total billed charges,575.74,31.95,,460.592,percent of total billed charges,31.95% of total billed charges,6223.94,7875,
ACCOLADE II HIP STEM 132 DEGREE #7,4400961,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,5.01,31.95,,4.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6224.94,7876,
T PLATE,4400962,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1504,902.4,,1579.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,528.66,35.15,,422.928,percent of total billed charges,35.15% of total billed charges,9.81,31.95,,7.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,571.52,38,,457.216,percent of total billed charges,38% of total billed charges,480.53,31.95,,384.424,percent of total billed charges,31.95% of total billed charges,6225.94,7877,
27in LONG SCREW 13mm,4400963,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,300,180,,315,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,114,38,,91.2,percent of total billed charges,38% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,6226.94,7878,
TRITANIUM ASYMMETRIC PATELLA A32mm X 10mm,4400964,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6227.94,7879,
TRIATHLON TRITANIUM ASYMMETRIC PATELLA A35mmX10mm,4400965,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6228.94,7880,
Glenoid Baseplate 28mm,4400966,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,18.44,31.95,,14.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,6229.94,7881,
Center Screw 4.5mm x 24mm,4400967,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,150,90,,157.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.73,35.15,,42.184,percent of total billed charges,35.15% of total billed charges,19.99,31.95,,15.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,57,38,,45.6,percent of total billed charges,38% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,6230.94,7882,
2.0MM BEADED SS CABLE SLEEVE SET,4400968,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,482,289.2,,506.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,169.42,35.15,,135.536,percent of total billed charges,35.15% of total billed charges,19.99,31.95,,15.992,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,183.16,38,,146.528,percent of total billed charges,38% of total billed charges,154,31.95,,123.2,percent of total billed charges,31.95% of total billed charges,6231.94,7883,
TRIATHOLON TRITANIUM ASYMMETRIC PATELLA 38mm X 11mm,4400969,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,20.87,31.95,,16.696,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6232.94,7884,
LEFT TIBIAL PLATEAU PLATE,4400970,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2960,1776,,3108,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1040.44,35.15,,832.352,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1124.8,38,,899.84,percent of total billed charges,38% of total billed charges,945.72,31.95,,756.576,percent of total billed charges,31.95% of total billed charges,6233.94,7885,
4.0 x 60 LOCKING SCREW,4400971,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,5.72,31.95,,4.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6234.94,7886,
5CC HYDRO SET XT,4400972,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2621,1572.6,,2752.05,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,921.28,35.15,,737.024,percent of total billed charges,35.15% of total billed charges,74.76,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,995.98,38,,796.784,percent of total billed charges,38% of total billed charges,837.41,31.95,,669.928,percent of total billed charges,31.95% of total billed charges,6235.94,7887,
132 NECK ANGLE HIP STEM,4400973,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6236.94,7888,
0 POLYETHYLENE INSERT,4400974,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6237.94,7889,
TRIATHLON TRITANIUM ASYMMETRIC PATELLA,4400975,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6238.94,7890,
ASNIS THREADED GUIDE WIRE 3.2x300,4400976,CDM,278,RC,C1769,HCPCS,OUTPATIENT,,,267,160.2,,280.35,105,,,case rate,pays based on 105% of threshold rate,133.5,50,,106.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,133.5,50,,106.8,percent of total billed charges,50% of total billed charges,93.85,35.15,,75.08,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,101.46,38,,81.168,percent of total billed charges,38% of total billed charges,85.31,31.95,,68.248,percent of total billed charges,31.95% of total billed charges,6239.94,7891,
NON LOCKING DRILL,4400977,CDM,272,RC,,,OUTPATIENT,,,406,243.6,,345.1,85,,276.08,Percent of total billed charges,85% of total billed charges,203,50,,162.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,203,50,,162.4,percent of total billed charges,50% of total billed charges,129.72,31.95,,103.776,percent of total billed charges,31.95% of total billed charges,129.72,31.95,,103.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,154.28,38,,123.424,percent of total billed charges,38% of total billed charges,162.4,40,,129.92,percent of total billed charges,40% of total billed charges,6240.94,7892,
LOCKING DRILL,4400978,CDM,272,RC,,,OUTPATIENT,,,422,253.2,,358.7,85,,286.96,Percent of total billed charges,85% of total billed charges,211,50,,168.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,211,50,,168.8,percent of total billed charges,50% of total billed charges,134.83,31.95,,107.864,percent of total billed charges,31.95% of total billed charges,134.83,31.95,,107.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,160.36,38,,128.288,percent of total billed charges,38% of total billed charges,168.8,40,,135.04,percent of total billed charges,40% of total billed charges,6241.94,7893,
Frame Fixator,4400979,CDM,272,RC,,,OUTPATIENT,,,1263,757.8,,1073.55,85,,858.84,Percent of total billed charges,85% of total billed charges,631.5,50,,505.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,631.5,50,,505.2,percent of total billed charges,50% of total billed charges,403.53,31.95,,322.824,percent of total billed charges,31.95% of total billed charges,403.53,31.95,,322.824,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,479.94,38,,383.952,percent of total billed charges,38% of total billed charges,505.2,40,,404.16,percent of total billed charges,40% of total billed charges,6242.94,7894,
SCREW DRIVER,4400980,CDM,270,RC,,,OUTPATIENT,,,447,268.2,,379.95,85,,303.96,Percent of total billed charges,85% of total billed charges,223.5,50,,178.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,223.5,50,,178.8,percent of total billed charges,50% of total billed charges,142.82,31.95,,114.256,percent of total billed charges,31.95% of total billed charges,142.82,31.95,,114.256,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,169.86,38,,135.888,percent of total billed charges,38% of total billed charges,178.8,40,,143.04,percent of total billed charges,40% of total billed charges,6243.94,7895,
14 R DIST TEMP PLATE,4400981,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4040,2424,,4242,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1420.06,35.15,,1136.048,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1535.2,38,,1228.16,percent of total billed charges,38% of total billed charges,1290.78,31.95,,1032.624,percent of total billed charges,31.95% of total billed charges,6244.94,7896,
5.0 PERIPROSTHETIC SCREW 12m,4400982,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,356,213.6,,373.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,125.13,35.15,,100.104,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.28,38,,108.224,percent of total billed charges,38% of total billed charges,113.74,31.95,,90.992,percent of total billed charges,31.95% of total billed charges,6245.94,7897,
5.0 LOCKING SCREW 36mm,4400983,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6246.94,7898,
5.0 LOCKING SCREW 70mm,4400984,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6247.94,7899,
5.0 LOCKING SCREW 42mm,4400985,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6248.94,7900,
5.0 LOCKING SCREW 46mm,4400986,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,21.42,31.95,,17.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6249.94,7901,
5.0 LOCKING SCREW 44mm,4400987,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,40.86,31.95,,32.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6250.94,7902,
5.0 LOCKING SCREW 60mm,4400988,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,58.56,31.95,,46.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6251.94,7903,
5.0 LOCKING SCREW 65mm,4400989,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,68.12,31.95,,54.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6252.94,7904,
WIRES 1.8m DIAMOND PC,4400990,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,132,79.2,,138.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,46.4,35.15,,37.12,percent of total billed charges,35.15% of total billed charges,71.46,31.95,,57.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.16,38,,40.128,percent of total billed charges,38% of total billed charges,42.17,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,6253.94,7905,
M6 NUT,4400991,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,39,23.4,,40.95,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.71,35.15,,10.968,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.82,38,,11.856,percent of total billed charges,38% of total billed charges,12.46,31.95,,9.968,percent of total billed charges,31.95% of total billed charges,6254.94,7906,
M8 NUT,4400992,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,38,22.8,,39.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,13.36,35.15,,10.688,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,14.44,38,,11.552,percent of total billed charges,38% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,6255.94,7907,
REAMER SHAFT 0227-8510S,4400993,CDM,272,RC,,,OUTPATIENT,,,918,550.8,,780.3,85,,624.24,Percent of total billed charges,85% of total billed charges,459,50,,367.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,459,50,,367.2,percent of total billed charges,50% of total billed charges,293.3,31.95,,234.64,percent of total billed charges,31.95% of total billed charges,293.3,31.95,,234.64,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,348.84,38,,279.072,percent of total billed charges,38% of total billed charges,367.2,40,,293.76,percent of total billed charges,40% of total billed charges,6256.94,7908,
4.2 X 130mm DRILL,4400994,CDM,272,RC,,,OUTPATIENT,,,411,246.6,,349.35,85,,279.48,Percent of total billed charges,85% of total billed charges,205.5,50,,164.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,205.5,50,,164.4,percent of total billed charges,50% of total billed charges,131.31,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,131.31,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,156.18,38,,124.944,percent of total billed charges,38% of total billed charges,164.4,40,,131.52,percent of total billed charges,40% of total billed charges,6257.94,7909,
9 X 405mm TIBIAL NAIL,4400995,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2812,1687.2,,2952.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,988.42,35.15,,790.736,percent of total billed charges,35.15% of total billed charges,12.08,31.95,,9.664,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1068.56,38,,854.848,percent of total billed charges,38% of total billed charges,898.43,31.95,,718.744,percent of total billed charges,31.95% of total billed charges,6258.94,7910,
5 X 60m LOCKING SCREW,4400996,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6259.94,7911,
5 x 65m LOCKING SCREW ADVANCED,4400997,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,411,246.6,,431.55,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,144.47,35.15,,115.576,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,156.18,38,,124.944,percent of total billed charges,38% of total billed charges,131.31,31.95,,105.048,percent of total billed charges,31.95% of total billed charges,6260.94,7912,
5 x 47.5m LOCKING SCREW,4400998,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6261.94,7913,
5 x 50m LOCKING SCREW,4400999,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,1019.77,31.95,,815.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6262.94,7914,
U-FRAME CARBON FIBER FOOT RING SHORT 155mm,4401000,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3271,1962.6,,3434.55,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1149.76,35.15,,919.808,percent of total billed charges,35.15% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1242.98,38,,994.384,percent of total billed charges,38% of total billed charges,1045.08,31.95,,836.064,percent of total billed charges,31.95% of total billed charges,6263.94,7915,
WASHER 7mm RED,4401001,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,68,40.8,,71.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.9,35.15,,19.12,percent of total billed charges,35.15% of total billed charges,236.75,31.95,,189.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.84,38,,20.672,percent of total billed charges,38% of total billed charges,21.73,31.95,,17.384,percent of total billed charges,31.95% of total billed charges,6264.94,7916,
CIRCLE FRAME CARBON FIBER FOOT RING SHORT 155mm,4401002,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2570,1542,,2698.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,903.36,35.15,,722.688,percent of total billed charges,35.15% of total billed charges,423.57,31.95,,338.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,976.6,38,,781.28,percent of total billed charges,38% of total billed charges,821.12,31.95,,656.896,percent of total billed charges,31.95% of total billed charges,6265.94,7917,
CIRCLE FRAME CARBON FIBER RING SEGMENT 155mm,4401003,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2132,1279.2,,2238.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,749.4,35.15,,599.52,percent of total billed charges,35.15% of total billed charges,202.88,31.95,,162.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,810.16,38,,648.128,percent of total billed charges,38% of total billed charges,681.17,31.95,,544.936,percent of total billed charges,31.95% of total billed charges,6266.94,7918,
ADAPTER WIRE BOLT LONG,4401004,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,148,88.8,,155.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,52.02,35.15,,41.616,percent of total billed charges,35.15% of total billed charges,595.61,31.95,,476.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,56.24,38,,44.992,percent of total billed charges,38% of total billed charges,47.29,31.95,,37.832,percent of total billed charges,31.95% of total billed charges,6267.94,7919,
ADAPTER WIRE BOLT MED,4401005,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,49,29.4,,51.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.22,35.15,,13.776,percent of total billed charges,35.15% of total billed charges,301.93,31.95,,241.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,18.62,38,,14.896,percent of total billed charges,38% of total billed charges,15.66,31.95,,12.528,percent of total billed charges,31.95% of total billed charges,6268.94,7920,
ROCKER BOLT 140mm,4401006,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2514,1508.4,,2639.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,883.67,35.15,,706.936,percent of total billed charges,35.15% of total billed charges,568.87,31.95,,455.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,955.32,38,,764.256,percent of total billed charges,38% of total billed charges,803.22,31.95,,642.576,percent of total billed charges,31.95% of total billed charges,6269.94,7921,
WASHER 4mm BLUE,4401007,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,68,40.8,,71.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.9,35.15,,19.12,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.84,38,,20.672,percent of total billed charges,38% of total billed charges,21.73,31.95,,17.384,percent of total billed charges,31.95% of total billed charges,6270.94,7922,
ADAPTOR WIRE BOLT OFFSET LONG,4401008,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,438,262.8,,459.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,153.96,35.15,,123.168,percent of total billed charges,35.15% of total billed charges,2.43,31.95,,1.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,166.44,38,,133.152,percent of total billed charges,38% of total billed charges,139.94,31.95,,111.952,percent of total billed charges,31.95% of total billed charges,6271.94,7923,
ADAPTOR WIRE BOLT SHORT,4401009,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,142,85.2,,149.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.91,35.15,,39.928,percent of total billed charges,35.15% of total billed charges,1.48,31.95,,1.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.96,38,,43.168,percent of total billed charges,38% of total billed charges,45.37,31.95,,36.296,percent of total billed charges,31.95% of total billed charges,6272.94,7924,
ADAPTOR STATIC STRUT LONG,4401010,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,124,74.4,,130.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,43.59,35.15,,34.872,percent of total billed charges,35.15% of total billed charges,1.71,31.95,,1.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,47.12,38,,37.696,percent of total billed charges,38% of total billed charges,39.62,31.95,,31.696,percent of total billed charges,31.95% of total billed charges,6273.94,7925,
ADAPTOR APEX PIN LONG,4401011,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,878,526.8,,921.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,308.62,35.15,,246.896,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,333.64,38,,266.912,percent of total billed charges,38% of total billed charges,280.52,31.95,,224.416,percent of total billed charges,31.95% of total billed charges,6274.94,7926,
ADAPTOR APEX PIN SHORT,4401012,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,752,451.2,,789.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,264.33,35.15,,211.464,percent of total billed charges,35.15% of total billed charges,1.63,31.95,,1.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285.76,38,,228.608,percent of total billed charges,38% of total billed charges,240.26,31.95,,192.208,percent of total billed charges,31.95% of total billed charges,6275.94,7927,
RODS THREADED ROD 6 x 300,4401013,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,116,69.6,,121.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.77,35.15,,32.616,percent of total billed charges,35.15% of total billed charges,8.19,31.95,,6.552,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,44.08,38,,35.264,percent of total billed charges,38% of total billed charges,37.06,31.95,,29.648,percent of total billed charges,31.95% of total billed charges,6276.94,7928,
3.2 x 400 RELOAD K-WIRE,4401014,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,321,192.6,,337.05,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.83,35.15,,90.264,percent of total billed charges,35.15% of total billed charges,15.61,31.95,,12.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,121.98,38,,97.584,percent of total billed charges,38% of total billed charges,102.56,31.95,,82.048,percent of total billed charges,31.95% of total billed charges,6277.94,7929,
REAMER,4401015,CDM,272,RC,,,OUTPATIENT,,,1306,783.6,,1110.1,85,,888.08,Percent of total billed charges,85% of total billed charges,653,50,,522.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,653,50,,522.4,percent of total billed charges,50% of total billed charges,417.27,31.95,,333.816,percent of total billed charges,31.95% of total billed charges,417.27,31.95,,333.816,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,496.28,38,,397.024,percent of total billed charges,38% of total billed charges,522.4,40,,417.92,percent of total billed charges,40% of total billed charges,6278.94,7930,
13 x 360 LEFT ALPHA GT,4401016,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3682,2209.2,,3866.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1294.22,35.15,,1035.376,percent of total billed charges,35.15% of total billed charges,28.44,31.95,,22.752,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1399.16,38,,1119.328,percent of total billed charges,38% of total billed charges,1176.4,31.95,,941.12,percent of total billed charges,31.95% of total billed charges,6279.94,7931,
RECON SCREW 6.5 x 80,4401017,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,376,225.6,,394.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,132.16,35.15,,105.728,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,142.88,38,,114.304,percent of total billed charges,38% of total billed charges,120.13,31.95,,96.104,percent of total billed charges,31.95% of total billed charges,6280.94,7932,
5 x 55 SCREW,4401018,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,6.96,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6281.94,7933,
5 x 40 SCREW,4401019,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,348,208.8,,365.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,122.32,35.15,,97.856,percent of total billed charges,35.15% of total billed charges,6.96,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,132.24,38,,105.792,percent of total billed charges,38% of total billed charges,111.19,31.95,,88.952,percent of total billed charges,31.95% of total billed charges,6282.94,7934,
10 HOLE R PLATE,4401020,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3870,2322,,4063.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1360.31,35.15,,1088.248,percent of total billed charges,35.15% of total billed charges,6.96,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1470.6,38,,1176.48,percent of total billed charges,38% of total billed charges,1236.47,31.95,,989.176,percent of total billed charges,31.95% of total billed charges,6283.94,7935,
DRILL BIT NON LOCKING 3.2 x 216,4401021,CDM,272,RC,,,OUTPATIENT,,,507,304.2,,430.95,85,,344.76,Percent of total billed charges,85% of total billed charges,253.5,50,,202.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,253.5,50,,202.8,percent of total billed charges,50% of total billed charges,161.99,31.95,,129.592,percent of total billed charges,31.95% of total billed charges,161.99,31.95,,129.592,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,192.66,38,,154.128,percent of total billed charges,38% of total billed charges,202.8,40,,162.24,percent of total billed charges,40% of total billed charges,6284.94,7936,
DRILL BIT 4.3,4401022,CDM,272,RC,,,OUTPATIENT,,,499,299.4,,424.15,85,,339.32,Percent of total billed charges,85% of total billed charges,249.5,50,,199.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,249.5,50,,199.6,percent of total billed charges,50% of total billed charges,159.43,31.95,,127.544,percent of total billed charges,31.95% of total billed charges,159.43,31.95,,127.544,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,189.62,38,,151.696,percent of total billed charges,38% of total billed charges,199.6,40,,159.68,percent of total billed charges,40% of total billed charges,6285.94,7937,
4.5 x 50 NON LOCKING SCREW,4401023,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,69,41.4,,72.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.25,35.15,,19.4,percent of total billed charges,35.15% of total billed charges,8.87,31.95,,7.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.22,38,,20.976,percent of total billed charges,38% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,6286.94,7938,
4.5 x 60 NON LOCKING SCREW,4401024,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,69,41.4,,72.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.25,35.15,,19.4,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.22,38,,20.976,percent of total billed charges,38% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,6287.94,7939,
4.5 x 70 NON LOCKING SCREW,4401025,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,69,41.4,,72.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.25,35.15,,19.4,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.22,38,,20.976,percent of total billed charges,38% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,6288.94,7940,
5.0 x 50 LOCKING SCREW,4401026,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6289.94,7941,
TRIDENT X3 0 POLYETHYLENE INSERT,4401027,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6290.94,7942,
OMNIFIT CEMENTED LONG STEM RIGHT,4401028,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,7525,4515,,7901.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2645.04,35.15,,2116.032,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2859.5,38,,2287.6,percent of total billed charges,38% of total billed charges,2404.24,31.95,,1923.392,percent of total billed charges,31.95% of total billed charges,6291.94,7943,
C-TAPER LFIT HEAD,4401029,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6292.94,7944,
RESTORE ANATOMIC HMSPHRCL SHELL 62MM RIGHT,4401030,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5375,3225,,5643.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1889.31,35.15,,1511.448,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2042.5,38,,1634,percent of total billed charges,38% of total billed charges,1717.31,31.95,,1373.848,percent of total billed charges,31.95% of total billed charges,6293.94,7945,
SCREW PLATE GAP 6.5MM X 50MM,4401031,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,242,145.2,,254.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,85.06,35.15,,68.048,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,91.96,38,,73.568,percent of total billed charges,38% of total billed charges,77.32,31.95,,61.856,percent of total billed charges,31.95% of total billed charges,6294.94,7946,
SCREW PLATE GAP 6.5MM X 35MM,4401032,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,242,145.2,,254.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,85.06,35.15,,68.048,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,91.96,38,,73.568,percent of total billed charges,38% of total billed charges,77.32,31.95,,61.856,percent of total billed charges,31.95% of total billed charges,6295.94,7947,
TRIATHLON X3 TIBIAL BEARING INSERT CS 4 13MM,4401033,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6296.94,7948,
ONETRAC LXS SUCTION STERILE TAPER TIP SGL USE,4401034,CDM,272,RC,,,OUTPATIENT,,,375,225,,318.75,85,,255,Percent of total billed charges,85% of total billed charges,187.5,50,,150,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,187.5,50,,150,percent of total billed charges,50% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,142.5,38,,114,percent of total billed charges,38% of total billed charges,150,40,,120,percent of total billed charges,40% of total billed charges,6297.94,7949,
OMNIFIT EON 132 CEM HIP STEM #4 C-TPR 25MM/100MM,4401035,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2700,1620,,2835,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,949.05,35.15,,759.24,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1026,38,,820.8,percent of total billed charges,38% of total billed charges,862.65,31.95,,690.12,percent of total billed charges,31.95% of total billed charges,6298.94,7950,
UHR UNIVERSAL HEAD BIPOLAR 41MM/26MM,4401036,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1350,810,,1417.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,474.53,35.15,,379.624,percent of total billed charges,35.15% of total billed charges,4.93,31.95,,3.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,513,38,,410.4,percent of total billed charges,38% of total billed charges,431.33,31.95,,345.064,percent of total billed charges,31.95% of total billed charges,6299.94,7951,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 11MM,4401037,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,168,100.8,,176.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,59.05,35.15,,47.24,percent of total billed charges,35.15% of total billed charges,6.68,31.95,,5.344,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,63.84,38,,51.072,percent of total billed charges,38% of total billed charges,53.68,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,6300.94,7952,
RESTORATION MODULAR HIP SYSTEM 19/+10/V40,4401038,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5975,3585,,6273.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2100.21,35.15,,1680.168,percent of total billed charges,35.15% of total billed charges,6.69,31.95,,5.352,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2270.5,38,,1816.4,percent of total billed charges,38% of total billed charges,1909.01,31.95,,1527.208,percent of total billed charges,31.95% of total billed charges,6301.94,7953,
LFIT V40 FEMORAL HEAD 26MM/+0MM,4401039,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,6.96,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6302.94,7954,
RESTORATION MODULAR HIP SYSTEM 155MM/14MM,4401040,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,4280,2568,,4494,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1504.42,35.15,,1203.536,percent of total billed charges,35.15% of total billed charges,6.96,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1626.4,38,,1301.12,percent of total billed charges,38% of total billed charges,1367.46,31.95,,1093.968,percent of total billed charges,31.95% of total billed charges,6303.94,7955,
DALL-MILES 2MM HOLES CABLE SLEEVE MED,4401041,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,275,165,,288.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,96.66,35.15,,77.328,percent of total billed charges,35.15% of total billed charges,6.96,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,104.5,38,,83.6,percent of total billed charges,38% of total billed charges,87.86,31.95,,70.288,percent of total billed charges,31.95% of total billed charges,6304.94,7956,
DALL-MILES CABLE 2.0MM/750MM,4401042,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,395,237,,414.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,138.84,35.15,,111.072,percent of total billed charges,35.15% of total billed charges,6.96,31.95,,5.568,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.1,38,,120.08,percent of total billed charges,38% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,6305.94,7957,
DALL-MILES CABLE AND SLEEVE SET 2.0MM,4401043,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,450,270,,472.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,158.18,35.15,,126.544,percent of total billed charges,35.15% of total billed charges,10.2,31.95,,8.16,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,171,38,,136.8,percent of total billed charges,38% of total billed charges,143.78,31.95,,115.024,percent of total billed charges,31.95% of total billed charges,6306.94,7958,
T7 HOOD W/ PEEL AWAY SHIELD,4401044,CDM,272,RC,,,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,45,50,,36,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,45,50,,36,percent of total billed charges,50% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,6307.94,7959,
14 HOLE PLATE,4401045,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2980,1788,,3129,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1047.47,35.15,,837.976,percent of total billed charges,35.15% of total billed charges,12.33,31.95,,9.864,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1132.4,38,,905.92,percent of total billed charges,38% of total billed charges,952.11,31.95,,761.688,percent of total billed charges,31.95% of total billed charges,6308.94,7960,
4.5 X 32 NON LOCKING SCREW,4401046,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,69,41.4,,72.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.25,35.15,,19.4,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.22,38,,20.976,percent of total billed charges,38% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,6309.94,7961,
4.5 X 36 NON LOCKING SCREW,4401047,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,69,41.4,,72.45,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.25,35.15,,19.4,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,26.22,38,,20.976,percent of total billed charges,38% of total billed charges,22.05,31.95,,17.64,percent of total billed charges,31.95% of total billed charges,6310.94,7962,
5.0 X 20 LOCKING SCREW,4401048,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6311.94,7963,
5.0 X 30 LOCKING SCREW,4401049,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6312.94,7964,
5.0 X 10 LOCKING SCREW,4401050,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6313.94,7965,
5.0 X 14 LOCKING SCREW,4401051,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6314.94,7966,
5.0 X 26 LOCKING SCREW,4401052,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6315.94,7967,
5.0 X 24 LOCKING SCREW,4401053,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6316.94,7968,
5.0 X 32 LOCKING SCREW,4401054,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6317.94,7969,
TRIDENT X3 0 DEG POLYETHYLENE INSERT 36MM,4401055,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6318.94,7970,
OMEGA PLATE 145 DGR 2 HOLE,4401056,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,974,584.4,,1022.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,342.36,35.15,,273.888,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,370.12,38,,296.096,percent of total billed charges,38% of total billed charges,311.19,31.95,,248.952,percent of total billed charges,31.95% of total billed charges,6319.94,7971,
LAG SCREW 100MM,4401057,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,496,297.6,,520.8,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,174.34,35.15,,139.472,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,188.48,38,,150.784,percent of total billed charges,38% of total billed charges,158.47,31.95,,126.776,percent of total billed charges,31.95% of total billed charges,6320.94,7972,
SHELL ACETABULAR CLUSTERHOLE TRIDENT II 54MM,4401058,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1800,1080,,1890,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,632.7,35.15,,506.16,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,684,38,,547.2,percent of total billed charges,38% of total billed charges,575.1,31.95,,460.08,percent of total billed charges,31.95% of total billed charges,6321.94,7973,
Triathlon CS Tibial Insert - X3 Size 1 16mm,4401059,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6322.94,7974,
Triathlon CS Tibial Insert - X3 Size 3 19mm,4401060,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6323.94,7975,
HUMERAL X3 INSERT 32X4MM,4401061,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,6324.94,7976,
HUMERAL PRESS-FIT STEM 9X93MM,4401062,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5550,3330,,5827.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1950.83,35.15,,1560.664,percent of total billed charges,35.15% of total billed charges,33.88,31.95,,27.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2109,38,,1687.2,percent of total billed charges,38% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,6325.94,7977,
CENTER SCREW 6.5MMX28MM,4401063,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,200,120,,210,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,56.24,percent of total billed charges,35.15% of total billed charges,46.15,31.95,,36.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76,38,,60.8,percent of total billed charges,38% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,6326.94,7978,
ADM/MDM X3 INSERT 28X48MM,4401064,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1245,747,,1307.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,437.62,35.15,,350.096,percent of total billed charges,35.15% of total billed charges,57.11,31.95,,45.688,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,473.1,38,,378.48,percent of total billed charges,38% of total billed charges,397.78,31.95,,318.224,percent of total billed charges,31.95% of total billed charges,6327.94,7979,
DRILL BIT 4.3MM,4401065,CDM,272,RC,,,OUTPATIENT,,,425,255,,361.25,85,,289,Percent of total billed charges,85% of total billed charges,212.5,50,,170,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,212.5,50,,170,percent of total billed charges,50% of total billed charges,135.79,31.95,,108.632,percent of total billed charges,31.95% of total billed charges,135.79,31.95,,108.632,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,161.5,38,,129.2,percent of total billed charges,38% of total billed charges,170,40,,136,percent of total billed charges,40% of total billed charges,6328.94,7980,
PLATE 12 HOLE LEFT DISTAL FEMUR,4401066,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3955,2373,,4152.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1390.18,35.15,,1112.144,percent of total billed charges,35.15% of total billed charges,71.36,31.95,,57.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1502.9,38,,1202.32,percent of total billed charges,38% of total billed charges,1263.62,31.95,,1010.896,percent of total billed charges,31.95% of total billed charges,6329.94,7981,
5.0 x 55 LOCKING SCREW,4401067,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6330.94,7982,
5.0 x 75 LOCKING SCREW,4401068,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,1.25,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6331.94,7983,
5.0 x 18 LOCKING SCREW,4401069,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,308,184.8,,323.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.26,35.15,,86.608,percent of total billed charges,35.15% of total billed charges,1.25,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,117.04,38,,93.632,percent of total billed charges,38% of total billed charges,98.41,31.95,,78.728,percent of total billed charges,31.95% of total billed charges,6332.94,7984,
2.5mm CANNULATED HEX DRIVER,4401070,CDM,272,RC,,,OUTPATIENT,,,545,327,,463.25,85,,370.6,Percent of total billed charges,85% of total billed charges,272.5,50,,218,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,272.5,50,,218,percent of total billed charges,50% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,174.13,31.95,,139.304,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,207.1,38,,165.68,percent of total billed charges,38% of total billed charges,218,40,,174.4,percent of total billed charges,40% of total billed charges,6333.94,7985,
HUMERAL X3 INSERT 36X6MM,4401071,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,1.25,31.95,,1,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,6334.94,7986,
GLENOSPHERE CONCENTRIC 36X2MM,4401072,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2175,1305,,2283.75,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,764.51,35.15,,611.608,percent of total billed charges,35.15% of total billed charges,4.2,31.95,,3.36,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,826.5,38,,661.2,percent of total billed charges,38% of total billed charges,694.91,31.95,,555.928,percent of total billed charges,31.95% of total billed charges,6335.94,7987,
HUMERAL MODULAR STEM 12X128MM,4401073,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5550,3330,,5827.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1950.83,35.15,,1560.664,percent of total billed charges,35.15% of total billed charges,6.48,31.95,,5.184,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2109,38,,1687.2,percent of total billed charges,38% of total billed charges,1773.23,31.95,,1418.584,percent of total billed charges,31.95% of total billed charges,6336.94,7988,
PLATE 14 HOLE NARROW COMPRESSION,4401074,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1400,840,,1470,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,492.1,35.15,,393.68,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,532,38,,425.6,percent of total billed charges,38% of total billed charges,447.3,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,6337.94,7989,
PLATE 12 HOLE NARROW COMPRESSION,4401075,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1400,840,,1470,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,492.1,35.15,,393.68,percent of total billed charges,35.15% of total billed charges,7.22,31.95,,5.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,532,38,,425.6,percent of total billed charges,38% of total billed charges,447.3,31.95,,357.84,percent of total billed charges,31.95% of total billed charges,6338.94,7990,
PLATE 10 HOLE NARROW LOCKING TRIANGLE 2.7,4401076,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1940,1164,,2037,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,681.91,35.15,,545.528,percent of total billed charges,35.15% of total billed charges,7.22,31.95,,5.776,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,737.2,38,,589.76,percent of total billed charges,38% of total billed charges,619.83,31.95,,495.864,percent of total billed charges,31.95% of total billed charges,6339.94,7991,
INSERT TIBIAL BEARING CS SZ 4 12MM,4401077,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6340.94,7992,
NAIL GAMMA3 S RT 10X180X130MM,4401078,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3595,2157,,3774.75,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1263.64,35.15,,1010.912,percent of total billed charges,35.15% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1366.1,38,,1092.88,percent of total billed charges,38% of total billed charges,1148.6,31.95,,918.88,percent of total billed charges,31.95% of total billed charges,6341.94,7993,
PATELLA ASYM TRIATHLON TRITANIUM 40X11MM,4401079,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,900,540,,945,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,316.35,35.15,,253.08,percent of total billed charges,35.15% of total billed charges,13.42,31.95,,10.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,342,38,,273.6,percent of total billed charges,38% of total billed charges,287.55,31.95,,230.04,percent of total billed charges,31.95% of total billed charges,6342.94,7994,
2.7MM XXL VOLAR DR PLATE STND LT 15 HOLES,4401080,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3268,1960.8,,3431.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1148.7,35.15,,918.96,percent of total billed charges,35.15% of total billed charges,16.61,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1241.84,38,,993.472,percent of total billed charges,38% of total billed charges,1044.13,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,6343.94,7995,
2.7MM XXL VOLAR DR PLATE STND RT 15 HOLES,4401081,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3268,1960.8,,3431.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1148.7,35.15,,918.96,percent of total billed charges,35.15% of total billed charges,17.25,31.95,,13.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1241.84,38,,993.472,percent of total billed charges,38% of total billed charges,1044.13,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,6344.94,7996,
2.7MM XXL VOLAR DR PLATE STND LT 11 HOLES,4401082,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3268,1960.8,,3431.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1148.7,35.15,,918.96,percent of total billed charges,35.15% of total billed charges,8.63,31.95,,6.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1241.84,38,,993.472,percent of total billed charges,38% of total billed charges,1044.13,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,6345.94,7997,
2.7MM XXL VOLAR DR PLATE STND RT 11 HOLES,4401083,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3268,1960.8,,3431.4,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1148.7,35.15,,918.96,percent of total billed charges,35.15% of total billed charges,126.81,31.95,,101.448,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1241.84,38,,993.472,percent of total billed charges,38% of total billed charges,1044.13,31.95,,835.304,percent of total billed charges,31.95% of total billed charges,6346.94,7998,
2.7MM XXL VOLAR DR PLATE STND LT 8 HOLES,4401084,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2858,1714.8,,3000.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1004.59,35.15,,803.672,percent of total billed charges,35.15% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1086.04,38,,868.832,percent of total billed charges,38% of total billed charges,913.13,31.95,,730.504,percent of total billed charges,31.95% of total billed charges,6347.94,7999,
2.7MM XXL VOLAR DR PLATE STND RT 8 HOLES,4401085,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2858,1714.8,,3000.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1004.59,35.15,,803.672,percent of total billed charges,35.15% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1086.04,38,,868.832,percent of total billed charges,38% of total billed charges,913.13,31.95,,730.504,percent of total billed charges,31.95% of total billed charges,6348.94,8000,
SCREW CANNULATED 4X34MM,4401086,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,298,178.8,,312.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,104.75,35.15,,83.8,percent of total billed charges,35.15% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,113.24,38,,90.592,percent of total billed charges,38% of total billed charges,95.21,31.95,,76.168,percent of total billed charges,31.95% of total billed charges,6349.94,8001,
PLATE 6 HOLE RT PRO TIBIA,4401087,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3085,1851,,3239.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1084.38,35.15,,867.504,percent of total billed charges,35.15% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1172.3,38,,937.84,percent of total billed charges,38% of total billed charges,985.66,31.95,,788.528,percent of total billed charges,31.95% of total billed charges,6350.94,8002,
3.5 X 36 NON LOCKING SCREW,4401088,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,140,84,,147,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.21,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,5271.75,31.95,,4217.4,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,6351.94,8003,
3.5 X 46 NON LOCKING SCREW,4401089,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,140,84,,147,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,49.21,35.15,,39.368,percent of total billed charges,35.15% of total billed charges,760.41,31.95,,608.328,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,6352.94,8004,
4.0 X 18 LOCKING SCREW,4401090,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,83.71,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6353.94,8005,
4.0 X 16 LOCKING SCREW,4401091,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,292,175.2,,306.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.64,35.15,,82.112,percent of total billed charges,35.15% of total billed charges,83.71,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,110.96,38,,88.768,percent of total billed charges,38% of total billed charges,93.29,31.95,,74.632,percent of total billed charges,31.95% of total billed charges,6354.94,8006,
Proximal Lateral Tibia Plate Axsos,4401092,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3024,1814.4,,3175.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1062.94,35.15,,850.352,percent of total billed charges,35.15% of total billed charges,83.71,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1149.12,38,,919.296,percent of total billed charges,38% of total billed charges,966.17,31.95,,772.936,percent of total billed charges,31.95% of total billed charges,6355.94,8007,
SCREW CORTICAL 3.5X60MM,4401093,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,60,36,,63,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.09,35.15,,16.872,percent of total billed charges,35.15% of total billed charges,83.71,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,6356.94,8008,
SCREW CANCELLOUS 4.0X46MM,4401094,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,66,39.6,,69.3,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,23.2,35.15,,18.56,percent of total billed charges,35.15% of total billed charges,83.71,31.95,,66.968,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,25.08,38,,20.064,percent of total billed charges,38% of total billed charges,21.09,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,6357.94,8009,
Vitoss BBTrauma Bone Graft Sub 10CC,4401095,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3950,2370,,4147.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1388.43,35.15,,1110.744,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1501,38,,1200.8,percent of total billed charges,38% of total billed charges,1262.03,31.95,,1009.624,percent of total billed charges,31.95% of total billed charges,6358.94,8010,
K-WIRE W/STOP 1.6X150MM,4401096,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,202,121.2,,212.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,71,35.15,,56.8,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,76.76,38,,61.408,percent of total billed charges,38% of total billed charges,64.54,31.95,,51.632,percent of total billed charges,31.95% of total billed charges,6359.94,8011,
T-Plate Narrow Locking 2.7 / 2x5 Holes L 47MM,4401097,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1722,1033.2,,1808.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,605.28,35.15,,484.224,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,654.36,38,,523.488,percent of total billed charges,38% of total billed charges,550.18,31.95,,440.144,percent of total billed charges,31.95% of total billed charges,6360.94,8012,
INSERT TIBIAL BEARING CS SZ 2 10MM,4401099,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6361.94,8013,
PROX LAT TIB PLATE RIGHT,4401100,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,3024,1814.4,,3175.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1062.94,35.15,,850.352,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1149.12,38,,919.296,percent of total billed charges,38% of total billed charges,966.17,31.95,,772.936,percent of total billed charges,31.95% of total billed charges,6362.94,8014,
SCREW CORTEX 3.5X55MM,4401101,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,60,36,,63,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.09,35.15,,16.872,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,6363.94,8015,
INSERT TIBIAL BEARING CS SZ 3 10MM,4401102,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6364.94,8016,
END CAP LOWER EXTREMITY 8 +0MM,4401103,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,317,190.2,,332.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,111.43,35.15,,89.144,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,120.46,38,,96.368,percent of total billed charges,38% of total billed charges,101.28,31.95,,81.024,percent of total billed charges,31.95% of total billed charges,6365.94,8017,
TIBIAL NAIL 10X330MM,4401104,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,2812,1687.2,,2952.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,988.42,35.15,,790.736,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1068.56,38,,854.848,percent of total billed charges,38% of total billed charges,898.43,31.95,,718.744,percent of total billed charges,31.95% of total billed charges,6366.94,8018,
SCREW ADVANCED LOCKING 5X60MM,4401105,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,412,247.2,,432.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,144.82,35.15,,115.856,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,156.56,38,,125.248,percent of total billed charges,38% of total billed charges,131.63,31.95,,105.304,percent of total billed charges,31.95% of total billed charges,6367.94,8019,
INSERT TRIDENT X3 O POLYETHYLENE 36MM,4401106,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6368.94,8020,
TRIATHLON FLUTED STEM 19MM X 100MM,4401107,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1745,1047,,1832.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,613.37,35.15,,490.696,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,663.1,38,,530.48,percent of total billed charges,38% of total billed charges,557.53,31.95,,446.024,percent of total billed charges,31.95% of total billed charges,6369.94,8021,
TRIATHLON BEARING INSERT SZ 5,4401108,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6370.94,8022,
TRIATHLON TIBIAL ASYMMETRIC CONE AUGMENT SZ B,4401109,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,6205,3723,,6515.25,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2181.06,35.15,,1744.848,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2357.9,38,,1886.32,percent of total billed charges,38% of total billed charges,1982.5,31.95,,1586,percent of total billed charges,31.95% of total billed charges,6371.94,8023,
ACCOLADE II 132 DEG NECK ANGLE HIP STEM,4401110,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,3600,2160,,3780,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1265.4,35.15,,1012.32,percent of total billed charges,35.15% of total billed charges,186.91,31.95,,149.528,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1368,38,,1094.4,percent of total billed charges,38% of total billed charges,1150.2,31.95,,920.16,percent of total billed charges,31.95% of total billed charges,6372.94,8024,
TRIATHLON X3 TIBIAL BEARING INSERT-CS #5 12MM,4401111,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,123.01,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6373.94,8025,
REUNION RSA X3 HUMERAL INSERT 36MM 8MM,4401112,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2900,1740,,3045,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1019.35,35.15,,815.48,percent of total billed charges,35.15% of total billed charges,123.01,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1102,38,,881.6,percent of total billed charges,38% of total billed charges,926.55,31.95,,741.24,percent of total billed charges,31.95% of total billed charges,6374.94,8026,
TRIATHLON X3 TIBIAL INSERT #6 12MM,4401113,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,123.01,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6375.94,8027,
HALF PIN EXT FIX 5/6MM 300 X 40MM TRANSFIX HOFFMANN 3 SS NS,4401114,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,270,162,,283.5,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,94.91,35.15,,75.928,percent of total billed charges,35.15% of total billed charges,123.01,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,102.6,38,,82.08,percent of total billed charges,38% of total billed charges,86.27,31.95,,69.016,percent of total billed charges,31.95% of total billed charges,6376.94,8028,
WRENCH SPANNER 7MM EXT FIX HOFFMANN II,4401115,CDM,272,RC,,,OUTPATIENT,,,610,366,,518.5,85,,414.8,Percent of total billed charges,85% of total billed charges,305,50,,244,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,305,50,,244,percent of total billed charges,50% of total billed charges,194.9,31.95,,155.92,percent of total billed charges,31.95% of total billed charges,194.9,31.95,,155.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,231.8,38,,185.44,percent of total billed charges,38% of total billed charges,244,40,,195.2,percent of total billed charges,40% of total billed charges,6377.94,8029,
RESTORATION ANATOMIC HEMI SHELL LEFT 56MM,4401116,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5380,3228,,5649,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1891.07,35.15,,1512.856,percent of total billed charges,35.15% of total billed charges,123.01,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2044.4,38,,1635.52,percent of total billed charges,38% of total billed charges,1718.91,31.95,,1375.128,percent of total billed charges,31.95% of total billed charges,6378.94,8030,
RESTORATION GAP PLATE 6.5MM SCREW 20MM,4401117,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,182,109.2,,191.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.97,35.15,,51.176,percent of total billed charges,35.15% of total billed charges,123.01,31.95,,98.408,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.16,38,,55.328,percent of total billed charges,38% of total billed charges,58.15,31.95,,46.52,percent of total billed charges,31.95% of total billed charges,6379.94,8031,
RESTORATION GAP PLATE 6.5MM SCREW 25MM,4401118,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,182,109.2,,191.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.97,35.15,,51.176,percent of total billed charges,35.15% of total billed charges,329.09,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.16,38,,55.328,percent of total billed charges,38% of total billed charges,58.15,31.95,,46.52,percent of total billed charges,31.95% of total billed charges,6380.94,8032,
RESTORATION GAP PLATE 6.5MM SCREW 15MM,4401119,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,182,109.2,,191.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.97,35.15,,51.176,percent of total billed charges,35.15% of total billed charges,329.09,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.16,38,,55.328,percent of total billed charges,38% of total billed charges,58.15,31.95,,46.52,percent of total billed charges,31.95% of total billed charges,6381.94,8033,
RESTORATION GAP PLATE 6.5MM SCREW 30MM,4401120,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,182,109.2,,191.1,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.97,35.15,,51.176,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,69.16,38,,55.328,percent of total billed charges,38% of total billed charges,58.15,31.95,,46.52,percent of total billed charges,31.95% of total billed charges,6382.94,8034,
SAW BLADE PRECISION THIN 9.0X0.38X25MM,4401121,CDM,270,RC,,,OUTPATIENT,,,114,68.4,,96.9,85,,77.52,Percent of total billed charges,85% of total billed charges,57,50,,45.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,57,50,,45.6,percent of total billed charges,50% of total billed charges,36.42,31.95,,29.136,percent of total billed charges,31.95% of total billed charges,36.42,31.95,,29.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,43.32,38,,34.656,percent of total billed charges,38% of total billed charges,45.6,40,,36.48,percent of total billed charges,40% of total billed charges,6383.94,8035,
BONE SCREW MINI CANN HD S/D 4X32MM,4401122,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,405,243,,425.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,142.36,35.15,,113.888,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,153.9,38,,123.12,percent of total billed charges,38% of total billed charges,129.4,31.95,,103.52,percent of total billed charges,31.95% of total billed charges,6384.94,8036,
TRIATHLON X3 TIBIAL BEARINGB INSERT-CS #4 14MM,4401123,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6385.94,8037,
TAP ASNIS III CANN AO FITTING 5MM,4401124,CDM,272,RC,,,OUTPATIENT,,,534,320.4,,453.9,85,,363.12,Percent of total billed charges,85% of total billed charges,267,50,,213.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,267,50,,213.6,percent of total billed charges,50% of total billed charges,170.61,31.95,,136.488,percent of total billed charges,31.95% of total billed charges,170.61,31.95,,136.488,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,202.92,38,,162.336,percent of total billed charges,38% of total billed charges,213.6,40,,170.88,percent of total billed charges,40% of total billed charges,6386.94,8038,
COUNTERSINK ASNIS III CANN AO CPLNG 5MM,4401125,CDM,272,RC,,,OUTPATIENT,,,398,238.8,,338.3,85,,270.64,Percent of total billed charges,85% of total billed charges,199,50,,159.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,199,50,,159.2,percent of total billed charges,50% of total billed charges,127.16,31.95,,101.728,percent of total billed charges,31.95% of total billed charges,127.16,31.95,,101.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,151.24,38,,120.992,percent of total billed charges,38% of total billed charges,159.2,40,,127.36,percent of total billed charges,40% of total billed charges,6387.94,8039,
BIT TWIST DRILL ASNIS III CANN AO QUICK CPLNG NS 3.5X150MM,4401126,CDM,270,RC,,,OUTPATIENT,,,584,350.4,,496.4,85,,397.12,Percent of total billed charges,85% of total billed charges,292,50,,233.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,292,50,,233.6,percent of total billed charges,50% of total billed charges,186.59,31.95,,149.272,percent of total billed charges,31.95% of total billed charges,186.59,31.95,,149.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,221.92,38,,177.536,percent of total billed charges,38% of total billed charges,233.6,40,,186.88,percent of total billed charges,40% of total billed charges,6388.94,8040,
BIT DRILL AO FLUTED 2.5X215MM,4401127,CDM,272,RC,,,OUTPATIENT,,,479,287.4,,407.15,85,,325.72,Percent of total billed charges,85% of total billed charges,239.5,50,,191.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,239.5,50,,191.6,percent of total billed charges,50% of total billed charges,153.04,31.95,,122.432,percent of total billed charges,31.95% of total billed charges,153.04,31.95,,122.432,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,182.02,38,,145.616,percent of total billed charges,38% of total billed charges,191.6,40,,153.28,percent of total billed charges,40% of total billed charges,6389.94,8041,
SCREW BONE ASNIS III CANN P/T TI 5X50MM,4401128,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,357,214.2,,374.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,125.49,35.15,,100.392,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.66,38,,108.528,percent of total billed charges,38% of total billed charges,114.06,31.95,,91.248,percent of total billed charges,31.95% of total billed charges,6390.94,8042,
SCREW BONE ASNIS III CANN P/T TI 5X48MM,4401129,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,357,214.2,,374.85,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,125.49,35.15,,100.392,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,135.66,38,,108.528,percent of total billed charges,38% of total billed charges,114.06,31.95,,91.248,percent of total billed charges,31.95% of total billed charges,6391.94,8043,
TRIATHLON X3 TIBIAL BEARING INSERT CS SZ4 10MM,4401130,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6392.94,8044,
SLEEVE DRILL AXSOS 3 LKG SHORT NS 4.3MM,4401131,CDM,270,RC,,,OUTPATIENT,,,438,262.8,,372.3,85,,297.84,Percent of total billed charges,85% of total billed charges,219,50,,175.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,219,50,,175.2,percent of total billed charges,50% of total billed charges,139.94,31.95,,111.952,percent of total billed charges,31.95% of total billed charges,139.94,31.95,,111.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,166.44,38,,133.152,percent of total billed charges,38% of total billed charges,175.2,40,,140.16,percent of total billed charges,40% of total billed charges,6393.94,8045,
WIRE K-WIRE AXSOS DRILL TIP 2X315MM,4401132,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,132,79.2,,138.6,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,46.4,35.15,,37.12,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,50.16,38,,40.128,percent of total billed charges,38% of total billed charges,42.17,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,6394.94,8046,
SCREW BONE AXSOS 3 LKG S/T TI 5X50MM,4401133,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,294,176.4,,308.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,103.34,35.15,,82.672,percent of total billed charges,35.15% of total billed charges,439.63,31.95,,351.704,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,111.72,38,,89.376,percent of total billed charges,38% of total billed charges,93.93,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,6395.94,8047,
SCREW BONE AXSOS 3 LKG S/T TI NS 5X40MM,4401134,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,294,176.4,,308.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,103.34,35.15,,82.672,percent of total billed charges,35.15% of total billed charges,710.89,31.95,,568.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,111.72,38,,89.376,percent of total billed charges,38% of total billed charges,93.93,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,6396.94,8048,
SCREW BONE AXSOS 3 LKG S/T TI 5X16MM,4401135,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,294,176.4,,308.7,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,103.34,35.15,,82.672,percent of total billed charges,35.15% of total billed charges,329.09,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,111.72,38,,89.376,percent of total billed charges,38% of total billed charges,93.93,31.95,,75.144,percent of total billed charges,31.95% of total billed charges,6397.94,8049,
SCREW BONE AXSOS 3 LKG PERIPROS S/T TI NS 5X10MM,4401136,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,341,204.6,,358.05,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,119.86,35.15,,95.888,percent of total billed charges,35.15% of total billed charges,329.09,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,129.58,38,,103.664,percent of total billed charges,38% of total billed charges,108.95,31.95,,87.16,percent of total billed charges,31.95% of total billed charges,6398.94,8050,
PLATE HIP OMEGA3 STD BARREL SS 135 DEG 4H 79MM,4401137,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1205,723,,1265.25,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,423.56,35.15,,338.848,percent of total billed charges,35.15% of total billed charges,329.09,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,457.9,38,,366.32,percent of total billed charges,38% of total billed charges,385,31.95,,308,percent of total billed charges,31.95% of total billed charges,6399.94,8051,
TRIDENT X3 ECCENTRIC INSERT #0 32MM,4401138,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,329.09,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6400.94,8052,
TRIATHLON ALL POLY TIBIAL INSERT CS #5 9MM,4401139,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,2550,1530,,2677.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,896.33,35.15,,717.064,percent of total billed charges,35.15% of total billed charges,329.09,31.95,,263.272,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,969,38,,775.2,percent of total billed charges,38% of total billed charges,814.73,31.95,,651.784,percent of total billed charges,31.95% of total billed charges,6401.94,8053,
TRIATHLON X3 BEARING INSERT CS SZ2 9MM,4401140,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1950,1170,,2047.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,685.43,35.15,,548.344,percent of total billed charges,35.15% of total billed charges,57.32,31.95,,45.856,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,741,38,,592.8,percent of total billed charges,38% of total billed charges,623.03,31.95,,498.424,percent of total billed charges,31.95% of total billed charges,6402.94,8054,
PLATE HIP OMEGA3 SHORT BARREL SS 130DEG 4H 79MM,4401141,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,951,570.6,,998.55,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,334.28,35.15,,267.424,percent of total billed charges,35.15% of total billed charges,122.26,31.95,,97.808,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,361.38,38,,289.104,percent of total billed charges,38% of total billed charges,303.84,31.95,,243.072,percent of total billed charges,31.95% of total billed charges,6403.94,8055,
BIT TWIST DRILL PANGEA AO 2.5X135MM,4401142,CDM,270,RC,,,OUTPATIENT,,,395,237,,335.75,85,,268.6,Percent of total billed charges,85% of total billed charges,197.5,50,,158,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,197.5,50,,158,percent of total billed charges,50% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,126.2,31.95,,100.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,150.1,38,,120.08,percent of total billed charges,38% of total billed charges,158,40,,126.4,percent of total billed charges,40% of total billed charges,6404.94,8056,
PLATE HUMERUS PANGEA PROXIMAL LEFT 6H NS 3.5X133MM,4401143,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,4580,2748,,4809,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1609.87,35.15,,1287.896,percent of total billed charges,35.15% of total billed charges,1335.04,31.95,,1068.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1740.4,38,,1392.32,percent of total billed charges,38% of total billed charges,1463.31,31.95,,1170.648,percent of total billed charges,31.95% of total billed charges,6405.94,8057,
SCREW BONE PANGEA LKG S/T SML FRAG NS T15 3.5X50MM,4401144,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,384,230.4,,403.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,134.98,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,116.736,percent of total billed charges,38% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,6406.94,8058,
SCREW BONE PANGEA LKG S/T SML FRAG NS T15 3.5X40MM,4401145,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,384,230.4,,403.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,134.98,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,116.736,percent of total billed charges,38% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,6407.94,8059,
SCREW BONE PANGEA LKG S/T SML FRAG NS T15 3.5X32MM,4401146,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,384,230.4,,403.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,134.98,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,116.736,percent of total billed charges,38% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,6408.94,8060,
SCREW BONE PANGEA LKG S/T SML FRAG NS T15 3.5X46MM,4401147,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,384,230.4,,403.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,134.98,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,116.736,percent of total billed charges,38% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,6409.94,8061,
SCREW BONE PANGEA LKG S/T SML FRAG NS T15 3.5X44MM,4401148,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,384,230.4,,403.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,134.98,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,116.736,percent of total billed charges,38% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,6410.94,8062,
SCREW BONE PANGEA LKG S/T SML FRAG NS T15 3.5X42MM,4401149,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,384,230.4,,403.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,134.98,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,116.736,percent of total billed charges,38% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,6411.94,8063,
SCREW BONE PANGEA LKG S/T SML FRAG NS T15 3.5X20MM,4401150,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,384,230.4,,403.2,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,134.98,35.15,,107.984,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,145.92,38,,116.736,percent of total billed charges,38% of total billed charges,122.69,31.95,,98.152,percent of total billed charges,31.95% of total billed charges,6412.94,8064,
SYSTEM RESTORATION MODULAR HIP V40 23MM/+30MM,4401151,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,5974,3584.4,,6272.7,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,2099.86,35.15,,1679.888,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,2270.12,38,,1816.096,percent of total billed charges,38% of total billed charges,1908.69,31.95,,1526.952,percent of total billed charges,31.95% of total billed charges,6413.94,8065,
INSERT X3 FOR MDM 28/38MM,4401152,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1243,745.8,,1305.15,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,436.91,35.15,,349.528,percent of total billed charges,35.15% of total billed charges,36.22,31.95,,28.976,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,472.34,38,,377.872,percent of total billed charges,38% of total billed charges,397.14,31.95,,317.712,percent of total billed charges,31.95% of total billed charges,6414.94,8066,
HEAD FEMORAL LFIT V40 28MM/+12MM,4401153,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,750,450,,787.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,263.63,35.15,,210.904,percent of total billed charges,35.15% of total billed charges,6.38,31.95,,5.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,285,38,,228,percent of total billed charges,38% of total billed charges,239.63,31.95,,191.704,percent of total billed charges,31.95% of total billed charges,6415.94,8067,
BASEPLATE TRIATHLON PRIMARY TIBIAL SZ2,4401154,CDM,278,RC,C1776,HCPCS,OUTPATIENT,,,1650,990,,1732.5,105,,,case rate,pays based on 105% of threshold rate,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,579.98,35.15,,463.984,percent of total billed charges,35.15% of total billed charges,7.77,31.95,,6.216,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,627,38,,501.6,percent of total billed charges,38% of total billed charges,527.18,31.95,,421.744,percent of total billed charges,31.95% of total billed charges,6416.94,8068,
PLATE BONE VARIAX BROAD LKG NS 2.4MM/10H L80MM,4401155,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1420,852,,1491,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,499.13,35.15,,399.304,percent of total billed charges,35.15% of total billed charges,9.93,31.95,,7.944,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,539.6,38,,431.68,percent of total billed charges,38% of total billed charges,453.69,31.95,,362.952,percent of total billed charges,31.95% of total billed charges,6417.94,8069,
COUNTERSINK ASNIS III CANN AO CPLNG 4MM,4401156,CDM,272,RC,,,OUTPATIENT,,,612,367.2,,520.2,85,,416.16,Percent of total billed charges,85% of total billed charges,306,50,,244.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,306,50,,244.8,percent of total billed charges,50% of total billed charges,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,195.53,31.95,,156.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,232.56,38,,186.048,percent of total billed charges,38% of total billed charges,244.8,40,,195.84,percent of total billed charges,40% of total billed charges,6418.94,8070,
GRIP TROCHANTERIC W/2 CABLES DALL-MILES LARGE,4401157,CDM,278,RC,C1713,HCPCS,OUTPATIENT,,,1658,994.8,,1740.9,105,,,case rate,pays based on 105% of threshold rate,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1147.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,582.79,35.15,,466.232,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,630.04,38,,504.032,percent of total billed charges,38% of total billed charges,529.73,31.95,,423.784,percent of total billed charges,31.95% of total billed charges,6419.94,8071,
"93005 Electrocardiogram, routine ECG w/ at least 12 leads; tracing only, w/o int",4420002,CDM,521,RC,93005,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,20.9,38,,16.72,percent of total billed charges,38% of total billed charges,22,40,,17.6,percent of total billed charges,40% of total billed charges,6420.94,8072,
Initial Remote Mntr Physiologic Parameters,4440003,CDM,510,RC,99453,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,392.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,392.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,11.18,31.95,,8.944,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,13.3,38,,10.64,percent of total billed charges,38% of total billed charges,14,40,,11.2,percent of total billed charges,40% of total billed charges,6421.94,8073,
Remote Mntr Physiologic Parameters Each 30 Days,4440004,CDM,510,RC,99454,HCPCS,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,125.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,125.85,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,41.8,38,,33.44,percent of total billed charges,38% of total billed charges,44,40,,35.2,percent of total billed charges,40% of total billed charges,6422.94,8074,
Remote Physiologic Mntr TX Mgmt 1st 20 Min,4440007,CDM,510,RC,99457,HCPCS,OUTPATIENT,,,95,57,,80.75,85,,64.6,Percent of total billed charges,85% of total billed charges,167.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,167.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,30.35,31.95,,24.28,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,36.1,38,,28.88,percent of total billed charges,38% of total billed charges,38,40,,30.4,percent of total billed charges,40% of total billed charges,6423.94,8075,
Remote Physiologic Mntr TX Mgmt Addl 20 Min,4440008,CDM,510,RC,99458,HCPCS,OUTPATIENT,,,78,46.8,,66.3,85,,53.04,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.92,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,24.92,31.95,,19.936,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,29.64,38,,23.712,percent of total billed charges,38% of total billed charges,31.2,40,,24.96,percent of total billed charges,40% of total billed charges,6424.94,8076,
ED VISIT LEVEL 1 Professional,4500001,CDM,981,RC,99281,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6425.94,8077,
ED VISIT LEVEL 2 Professional,4500002,CDM,981,RC,99282,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6426.94,8078,
ED VISIT LEVEL 3 Professional,4500003,CDM,981,RC,99283,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,68.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6427.94,8079,
ED VISIT LEVEL 4 Professional,4500004,CDM,981,RC,99284,HCPCS,OUTPATIENT,,,490,294,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6428.94,8080,
ED VISIT LEVEL 5 Professional,4500005,CDM,981,RC,99285,HCPCS,OUTPATIENT,,,740,444,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,193.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,168.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6429.94,8081,
Critical care first hour,4500010,CDM,981,RC,99291,HCPCS,OUTPATIENT,,,920,552,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,280.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,203.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6430.94,8082,
Critical care addl 30 min,4500011,CDM,981,RC,99292,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,102.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6431.94,8083,
MOD SED SAME PHYS/QHP INITIAL 15 MINS <5 YRS,4500050,CDM,981,RC,99151,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,22.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6432.94,8084,
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,4500052,CDM,981,RC,99152,HCPCS,OUTPATIENT,,,55,33,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,11.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6433.94,8085,
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,4500054,CDM,981,RC,99153,HCPCS,OUTPATIENT,,,40,24,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,9.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,10.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6434.94,8086,
Drainage of skin abscess,4500100,CDM,981,RC,10060,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6435.94,8087,
Fna bx w/o img gdn 1st les,4500102,CDM,981,RC,10021,HCPCS,OUTPATIENT,,,230,138,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,106,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6436.94,8088,
DRAINAGE FINGER ABSCESS SIMPLE,4500103,CDM,981,RC,26010,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,397.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,132.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6437.94,8089,
Drainage of skin abscess,4500120,CDM,981,RC,10061,HCPCS,OUTPATIENT,,,560,336,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,225.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6438.94,8090,
DRAINAGE PILONIDAL CYST SIMPLE,4500125,CDM,981,RC,10080,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6439.94,8091,
DRAINAGE PILONIDAL CYST COMPLICATED,4500126,CDM,981,RC,10081,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,296.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,161.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6440.94,8092,
Remove foreign body,4500140,CDM,981,RC,10120,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,162,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6441.94,8093,
Removal of foreign body; complicated,4500142,CDM,981,RC,10121,HCPCS,OUTPATIENT,,,650,390,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,295.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6442.94,8094,
Drainage of hematoma/fluid,4500160,CDM,981,RC,10140,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6443.94,8095,
Puncture drainage of lesion,4500180,CDM,981,RC,10160,HCPCS,OUTPATIENT,,,310,186,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6444.94,8096,
PROF PUNCH BIOPSY SKIN SINGLE LESION,4500184,CDM,981,RC,11104,HCPCS,OUTPATIENT,,,293,175.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6445.94,8097,
Shave skin lesion 0.5 cm/<,4500190,CDM,981,RC,11310,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6446.94,8098,
Exc tr-ext b9+marg 0.5 cm<,4500200,CDM,981,RC,11400,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,132.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6447.94,8099,
Exc tr-ext b9+marg 0.6-1 cm,4500220,CDM,981,RC,11401,HCPCS,OUTPATIENT,,,370,222,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,162.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6448.94,8100,
EXC B9 LES MRGN XCP SK TG T/A/L 1.1-2.0 CM PROF,4500221,CDM,981,RC,11402,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6449.94,8101,
DBRDMT SUBCUTANEOUS TISSUE 20 SQ CM/< PROF,4500222,CDM,981,RC,11042,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,57.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6450.94,8102,
Exc face-mm b9+marg 0.5 cm/<,4500240,CDM,981,RC,11440,HCPCS,OUTPATIENT,,,330,198,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6451.94,8103,
Exc face-mm b9+marg 0.6-1 cm,4500260,CDM,981,RC,11441,HCPCS,OUTPATIENT,,,440,264,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,182.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6452.94,8104,
Removal of nail plate,4500280,CDM,981,RC,11730,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,51.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6453.94,8105,
11732 AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL,4500285,CDM,981,RC,11732,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,16.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6454.94,8106,
Drain blood from under nail,4500300,CDM,981,RC,11740,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,29.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6455.94,8107,
Removal of nail bed,4500320,CDM,981,RC,11750,HCPCS,OUTPATIENT,,,430,258,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,166.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,96.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6456.94,8108,
Repair of nail bed,4500340,CDM,981,RC,11760,HCPCS,OUTPATIENT,,,480,288,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,205.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6457.94,8109,
Rpr s/n/ax/gen/trnk 2.5cm/<,4500360,CDM,981,RC,12001,HCPCS,OUTPATIENT,,,210,126,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6458.94,8110,
Rpr s/n/ax/gen/trnk2.6-7.5cm,4500380,CDM,981,RC,12002,HCPCS,OUTPATIENT,,,270,162,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,117.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,56.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6459.94,8111,
Rpr s/n/ax/gen/trk7.6-12.5cm,4500400,CDM,981,RC,12004,HCPCS,OUTPATIENT,,,340,204,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6460.94,8112,
Rpr s/n/a/gen/trk12.6-20.0cm,4500420,CDM,981,RC,12005,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6461.94,8113,
Rpr s/n/a/gen/trk20.1-30.0cm,4500440,CDM,981,RC,12006,HCPCS,OUTPATIENT,,,540,324,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,213.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6462.94,8114,
Rpr f/e/e/n/l/m 2.5 cm/<,4500460,CDM,981,RC,12011,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,117.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6463.94,8115,
Rpr f/e/e/n/l/m 2.6-5.0 cm,4500480,CDM,981,RC,12013,HCPCS,OUTPATIENT,,,290,174,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,123.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6464.94,8116,
Rpr f/e/e/n/l/m 5.1-7.5 cm,4500500,CDM,981,RC,12014,HCPCS,OUTPATIENT,,,360,216,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,148.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6465.94,8117,
Rpr f/e/e/n/l/m 7.6-12.5 cm,4500520,CDM,981,RC,12015,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6466.94,8118,
Rpr fe/e/en/l/m 12.6-20.0 cm,4500525,CDM,981,RC,12016,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,228.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,123.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6467.94,8119,
TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,4500530,CDM,981,RC,12020,HCPCS,OUTPATIENT,,,560,336,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,309.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6468.94,8120,
Intmd rpr s/a/t/ext 2.5 cm/<,4500540,CDM,981,RC,12031,HCPCS,OUTPATIENT,,,550,330,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,262.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,141.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6469.94,8121,
Intmd rpr s/a/t/ext 2.6-7.5,4500560,CDM,981,RC,12032,HCPCS,OUTPATIENT,,,680,408,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,325.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6470.94,8122,
Intmd rpr s/tr/ext 7.6-12.5,4500580,CDM,981,RC,12034,HCPCS,OUTPATIENT,,,760,456,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,344.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,192.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6471.94,8123,
Intmd rpr s/a/t/ext 12.6-20,4500600,CDM,981,RC,12035,HCPCS,OUTPATIENT,,,920,552,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,414.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,227.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6472.94,8124,
Intmd rpr n-hf/genit 2.5cm/<,4500620,CDM,981,RC,12041,HCPCS,OUTPATIENT,,,560,336,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,262.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,136.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6473.94,8125,
Intmd rpr n-hf/genit2.6-7.5,4500640,CDM,981,RC,12042,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,318.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,183.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6474.94,8126,
Intmd rpr n-hf/genit7.6-12.5,4500660,CDM,981,RC,12044,HCPCS,OUTPATIENT,,,840,504,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,393.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,201.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6475.94,8127,
Intmd rpr n-hf/genit12.6-20,4500663,CDM,981,RC,12045,HCPCS,OUTPATIENT,,,970,582,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,434.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,256.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6476.94,8128,
Intmd rpr face/mm 2.5 cm/<,4500680,CDM,981,RC,12051,HCPCS,OUTPATIENT,,,620,372,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,285.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,158.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6477.94,8129,
Intmd rpr face/mm 2.6-5.0 cm,4500700,CDM,981,RC,12052,HCPCS,OUTPATIENT,,,720,432,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,324.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,186.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6478.94,8130,
Intmd rpr face/mm 5.1-7.5 cm,4500703,CDM,981,RC,12053,HCPCS,OUTPATIENT,,,840,504,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,378.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,202.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6479.94,8131,
Intmd rpr face/mm 7.6-12.5cm,4500704,CDM,981,RC,12054,HCPCS,OUTPATIENT,,,880,528,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,397.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6480.94,8132,
Cmplx rpr trunk 1.1-2.5 cm,4500706,CDM,981,RC,13100,HCPCS,OUTPATIENT,,,810,486,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,365.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,187.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6481.94,8133,
Cmplx rpr trunk 2.6-7.5 cm,4500708,CDM,981,RC,13101,HCPCS,OUTPATIENT,,,960,576,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,430.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,230.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6482.94,8134,
Cmplx rpr s/a/l 1.1-2.5 cm,4500710,CDM,981,RC,13120,HCPCS,OUTPATIENT,,,1020,612,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,382.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,216.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6483.94,8135,
Cmplx rpr s/a/l 2.6-7.5 cm,4500711,CDM,981,RC,13121,HCPCS,OUTPATIENT,,,1040,624,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,464.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,241.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6484.94,8136,
Cmplx rpr s/a/l addl 5 cm/>,4500712,CDM,981,RC,13122,HCPCS,OUTPATIENT,,,320,192,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,144.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6485.94,8137,
Cmplx rpr f/c/c/m/n/ax/g/h/f 1.1-2.5 cm,4500714,CDM,981,RC,13131,HCPCS,OUTPATIENT,,,940,564,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,420.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,226.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6486.94,8138,
Cmplx rpr f/c/c/m/n/ax/g/h/f 2.6-7.5 cm,4500715,CDM,981,RC,13132,HCPCS,OUTPATIENT,,,1160,696,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,519.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,283.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6487.94,8139,
Cmplx rpr F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/,4500716,CDM,981,RC,13133,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,195.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,118.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6488.94,8140,
Cmplx rpr e/n/e/l 1.1-2.5 cm,4500717,CDM,981,RC,13151,HCPCS,OUTPATIENT,,,1030,618,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,260.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6489.94,8141,
Cmplx rpr e/n/e/l 2.6-7.5 cm,4500718,CDM,981,RC,13152,HCPCS,OUTPATIENT,,,1230,738,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,552.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,314.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6490.94,8142,
Initial treatment of burn(s),4500720,CDM,981,RC,16000,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6491.94,8143,
Dress/debrid p-thick burn <10%,4500740,CDM,981,RC,16020,HCPCS,OUTPATIENT,,,220,132,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,87.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6492.94,8144,
Dress/debrid p-thick burn m,4500750,CDM,981,RC,16025,HCPCS,OUTPATIENT,,,360,216,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,163.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,105.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6493.94,8145,
Dress/debrid p-thick burn >10%,4500760,CDM,981,RC,16030,HCPCS,OUTPATIENT,,,560,336,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6494.94,8146,
CHEM CAUT GRANULATION TISSUE PROF,4500767,CDM,981,RC,17250,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,85.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6495.94,8147,
PROF SUTURE OR STAPLE RMVL W/ ANES,4500771,CDM,981,RC,15851,HCPCS,OUTPATIENT,,,178,106.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,61.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6496.94,8148,
PROF SUTURE OR STAPLE RMVL W/O ANES,4500773,CDM,981,RC,15853,HCPCS,OUTPATIENT,,,33,19.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,10.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6497.94,8149,
PROF SUTURE AND STAPLE RMVL W/O ANES,4500774,CDM,981,RC,15854,HCPCS,OUTPATIENT,,,46,27.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6498.94,8150,
Removal of foreign body,4500780,CDM,981,RC,20520,HCPCS,OUTPATIENT,,,540,324,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,307.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6499.94,8151,
PROF RMVL FB MUSCLE/TENDON SHEATH DEEP/COMP,4500785,CDM,981,RC,20525,HCPCS,OUTPATIENT,,,1023,613.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,708.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,233.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6500.94,8152,
Inj trigger point 1/2 muscl,4500800,CDM,981,RC,20552,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,83.17,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,34.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6501.94,8153,
20553 PROF Inject trigger points 3/>,4500801,CDM,981,RC,20553,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6502.94,8154,
Drain/inj joint/bursa w/o us,4500820,CDM,981,RC,20600,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,34.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6503.94,8155,
Drain/inj joint/bursa w/o us,4500840,CDM,981,RC,20605,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6504.94,8156,
Drain/inj joint/bursa w/o us,4500860,CDM,981,RC,20610,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6505.94,8157,
Reset dislocated jaw,4500885,CDM,981,RC,21480,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,157.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,29.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6506.94,8158,
Treat clavicle fracture,4500900,CDM,981,RC,23500,HCPCS,OUTPATIENT,,,590,354,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,329.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,220,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6507.94,8159,
Treat shoulder dislocation,4500920,CDM,981,RC,23650,HCPCS,OUTPATIENT,,,840,504,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,482.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,290.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6508.94,8160,
Treat shoulder dislocation,4500940,CDM,981,RC,23655,HCPCS,OUTPATIENT,,,1180,708,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,619.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,389.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6509.94,8161,
Treat elbow closed dislocation w/o anes,4500950,CDM,981,RC,24600,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,562.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,331.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6510.94,8162,
Treat elbow dislocation,4500960,CDM,981,RC,24640,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6511.94,8163,
CLOSED TX RADIALULNAR SHAFT FRACTURES W/MANJ,4500970,CDM,981,RC,25565,HCPCS,OUTPATIENT,,,1260,756,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,783.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,447.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6512.94,8164,
Treat fracture radius/ulna,4500980,CDM,981,RC,25605,HCPCS,OUTPATIENT,,,1480,888,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,823.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6513.94,8165,
26011 DRAINAGE FINGER ABSCESS COMPLICATED PROF,4500990,CDM,981,RC,26011,HCPCS,OUTPATIENT,,,455,273,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,590.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,174.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6514.94,8166,
Treat knuckle dislocation,4501000,CDM,981,RC,26700,HCPCS,OUTPATIENT,,,880,528,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,498.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,303.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6515.94,8167,
CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA,4501015,CDM,981,RC,26750,HCPCS,OUTPATIENT,,,545,327,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,276.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,183.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6516.94,8168,
Treat finger fracture each,4501020,CDM,981,RC,26755,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,474.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,265.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6517.94,8169,
Treat finger dislocation,4501040,CDM,981,RC,26770,HCPCS,OUTPATIENT,,,730,438,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,420.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,255.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6518.94,8170,
27238 CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ,4501048,CDM,981,RC,27238,HCPCS,OUTPATIENT,,,1390,834,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,713.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,446.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6519.94,8171,
27240 CLTX INTR/PERI/SBTRCHNTC FEMORAL FX W/MANJ,4501050,CDM,981,RC,27240,HCPCS,OUTPATIENT,,,2900,1740,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1502.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,904.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6520.94,8172,
Treat hip dislocation,4501060,CDM,981,RC,27250,HCPCS,OUTPATIENT,,,740,444,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,290.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6521.94,8173,
CLTX HIP DISLOCATION TRAUMATIC REQ ANES PROF,4501061,CDM,981,RC,27252,HCPCS,OUTPATIENT,,,2150,1290,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1187.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,712.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6522.94,8174,
Treat kneecap dislocation,4501080,CDM,981,RC,27560,HCPCS,OUTPATIENT,,,950,570,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,557.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,329.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6523.94,8175,
CLTX POST HIP ARTHRP DISLC REQ ANES PF,4501086,CDM,981,RC,27266,HCPCS,OUTPATIENT,,,1760,1056,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,906.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,555.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6524.94,8176,
27267 CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MANJ ED ProFe,4501087,CDM,981,RC,27267,HCPCS,OUTPATIENT,,,1300,780,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,668.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,422.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6525.94,8177,
27268 CLOSED TX FEMORAL FRACTURE PROX HEAD W/MANJ ED ProFee,4501088,CDM,981,RC,27268,HCPCS,OUTPATIENT,,,1630,978,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,836.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,519.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6526.94,8178,
CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,4501095,CDM,981,RC,27752,HCPCS,OUTPATIENT,,,1450,870,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,821.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,469.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6527.94,8179,
27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANJ PROF,4501098,CDM,981,RC,27788,HCPCS,OUTPATIENT,,,760,456,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,642.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,370.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6528.94,8180,
CLTX BIMALLEOLAR ANKLE FRACTURE W/O MANJ PROF,4501099,CDM,981,RC,27808,HCPCS,OUTPATIENT,,,895,537,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,293.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6529.94,8181,
Treatment of ankle fracture,4501100,CDM,981,RC,27818,HCPCS,OUTPATIENT,,,1330,798,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,741.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,424.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6530.94,8182,
27840 CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA,4501104,CDM,981,RC,27840,HCPCS,OUTPATIENT,,,1130,678,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,372.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6531.94,8183,
27842 CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIXJ,4501106,CDM,981,RC,27842,HCPCS,OUTPATIENT,,,1485,891,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,758.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,470.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6532.94,8184,
MANIPULATION ANKLE UNDER GENERAL ANESTHESIA,4501110,CDM,981,RC,27860,HCPCS,OUTPATIENT,,,420,252,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,265.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,155.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6533.94,8185,
Treatment of toe fracture,4501120,CDM,981,RC,28515,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,244.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,136.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6534.94,8186,
Treat toe dislocation,4501140,CDM,981,RC,28660,HCPCS,OUTPATIENT,,,330,198,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,89.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6535.94,8187,
Application of forearm cast,4501160,CDM,981,RC,29075,HCPCS,OUTPATIENT,,,220,132,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,129.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,58.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6536.94,8188,
Apply hand/wrist cast,4501180,CDM,981,RC,29085,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,141.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,63.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6537.94,8189,
Apply long arm splint,4501200,CDM,981,RC,29105,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,122.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6538.94,8190,
Apply forearm splint,4501220,CDM,981,RC,29125,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6539.94,8191,
27502 CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ,4501222,CDM,981,RC,27502,HCPCS,OUTPATIENT,,,2300,1380,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1191.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,718.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6540.94,8192,
Application of finger splint,4501240,CDM,981,RC,29130,HCPCS,OUTPATIENT,,,110,66,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,62.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,27.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6541.94,8193,
Strapping of shoulder,4501260,CDM,981,RC,29240,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,17.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6542.94,8194,
Strapping of elbow or wrist,4501280,CDM,981,RC,29260,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,18.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6543.94,8195,
Strapping of hand or finger,4501300,CDM,981,RC,29280,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,19.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6544.94,8196,
Apply short leg cast,4501320,CDM,981,RC,29405,HCPCS,OUTPATIENT,,,220,132,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,121.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6545.94,8197,
Application long leg splint,4501340,CDM,981,RC,29505,HCPCS,OUTPATIENT,,,210,126,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,126.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6546.94,8198,
Application lower leg splint,4501360,CDM,981,RC,29515,HCPCS,OUTPATIENT,,,210,126,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,106.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6547.94,8199,
Strapping of knee,4501380,CDM,981,RC,29530,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,17.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6548.94,8200,
Strapping of ankle and/or ft,4501400,CDM,981,RC,29540,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,16.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6549.94,8201,
Strapping of toes,4501420,CDM,981,RC,29550,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,29.17,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,10.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6550.94,8202,
Removal/revision of cast,4501440,CDM,981,RC,29705,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6551.94,8203,
Remove nasal foreign body,4501460,CDM,981,RC,30300,HCPCS,OUTPATIENT,,,360,216,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,268.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6552.94,8204,
Control of nosebleed simple,4501480,CDM,981,RC,30901,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,201.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6553.94,8205,
Control of nosebleed complex,4501500,CDM,981,RC,30903,HCPCS,OUTPATIENT,,,240,144,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,316.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6554.94,8206,
CTRL NSL HEMRRG PST NASAL PACKS/CAUTERY 1 ST Prof,4501505,CDM,981,RC,30905,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,477.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,101.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6555.94,8207,
Insert emergency airway,4501520,CDM,981,RC,31500,HCPCS,OUTPATIENT,,,570,342,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,225.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,134.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6556.94,8208,
Change of windpipe airway,4501540,CDM,981,RC,31502,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6557.94,8209,
Dx laryngoscopy Excl Nb,4501550,CDM,981,RC,31525,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,373.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,151.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6558.94,8210,
PROF LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,4501555,CDM,981,RC,31575,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,171.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,64.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6559.94,8211,
Incision of windpipe,4501560,CDM,981,RC,31603,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,513.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,304.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6560.94,8212,
31605 TRACHEOSTOMY ER CRICOTHYROID,4501562,CDM,981,RC,31605,HCPCS,OUTPATIENT,,,1050,630,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,533.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,314.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6561.94,8213,
Clearance of airways,4501570,CDM,981,RC,31720,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6562.94,8214,
Insertion of chest tube,4501580,CDM,981,RC,32551,HCPCS,OUTPATIENT,,,620,372,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,147.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6563.94,8215,
Aspirate pleura w/o imaging,4501600,CDM,981,RC,32554,HCPCS,OUTPATIENT,,,520,312,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,310.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,84.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6564.94,8216,
Aspirate pleura w/ imaging,4501620,CDM,981,RC,32555,HCPCS,OUTPATIENT,,,670,402,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,436.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6565.94,8217,
33206 INS NEW/RPLCMT PRM PACEMAKR W/TRANS ELTRD ATRIA,4501622,CDM,981,RC,33206,HCPCS,OUTPATIENT,,,1170,702,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,795.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,424.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6566.94,8218,
33207 INS NEW/RPLC PRM PACEMAKER W/TRANSV ELTRD VENTR,4501624,CDM,981,RC,33207,HCPCS,OUTPATIENT,,,1240,744,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,847.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,446.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6567.94,8219,
33208 INS NEW/RPLCMT PRM PM W/TRANSV ELTRD ATRIALVENT,4501625,CDM,981,RC,33208,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,919.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6568.94,8220,
33210 INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH,4501627,CDM,981,RC,33210,HCPCS,OUTPATIENT,,,430,258,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,292.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,151.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6569.94,8221,
33211 INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX,4501629,CDM,981,RC,33211,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,303.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,158.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6570.94,8222,
Place catheter in vein,4501630,CDM,981,RC,36010,HCPCS,OUTPATIENT,,,1170,702,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,798.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,102.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6571.94,8223,
Insert non-tunnel cv cath <5yo,4501640,CDM,981,RC,36555,HCPCS,OUTPATIENT,,,550,330,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,305.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,80.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6572.94,8224,
Insert non-tunnel cv cath >4yo,4501660,CDM,981,RC,36556,HCPCS,OUTPATIENT,,,265,159,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,341.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,80.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6573.94,8225,
INSJ PRPH CVC W/O SUBQ PORT/PMP AGE 5 YR/>,4501670,CDM,981,RC,36569,HCPCS,OUTPATIENT,,,290,174,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,164.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,89.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6574.94,8226,
PROF RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP,4501674,CDM,981,RC,36581,HCPCS,OUTPATIENT,,,520,312,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1197.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,171.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6575.94,8227,
Insertion catheter artery,4501680,CDM,981,RC,36620,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6576.94,8228,
Insert needle bone cavity,4501700,CDM,981,RC,36680,HCPCS,OUTPATIENT,,,230,138,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,57,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6577.94,8229,
Drainage of gum lesion,4501710,CDM,981,RC,41800,HCPCS,OUTPATIENT,,,680,408,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,421.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,142.03,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6578.94,8230,
42000 DRAINAGE ABSCESS PALATE UVULA,4501715,CDM,981,RC,42000,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,231.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,102.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6579.94,8231,
Remove pharynx foreign body,4501720,CDM,981,RC,42809,HCPCS,OUTPATIENT,,,470,282,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,301.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6580.94,8232,
NASO/ORO-GASTRIC TUBE PLCMT W/FLUORO PROF,4501739,CDM,981,RC,43752,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,64.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6581.94,8233,
Tx gastro intub w/asp,4501740,CDM,981,RC,43753,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6582.94,8234,
PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,4501750,CDM,981,RC,43762,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,319.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6583.94,8235,
45900 RDCT PROCIDENTIA UNDER ANES SEP PROC,4501755,CDM,981,RC,45900,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,317.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,201.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6584.94,8236,
Incision of anal abscess,4501760,CDM,981,RC,46050,HCPCS,OUTPATIENT,,,540,324,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,308.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6585.94,8237,
Incise external hemorrhoid,4501780,CDM,981,RC,46083,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,272.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6586.94,8238,
Removal of anal tags,4501790,CDM,981,RC,46230,HCPCS,OUTPATIENT,,,680,408,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,426.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,164.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6587.94,8239,
Removal of hemorrhoid clot,4501800,CDM,981,RC,46320,HCPCS,OUTPATIENT,,,340,204,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,284.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6588.94,8240,
Abd paracentesis,4501820,CDM,981,RC,49082,HCPCS,OUTPATIENT,,,390,234,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,291.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6589.94,8241,
Abd paracentesis w/imaging,4501840,CDM,981,RC,49083,HCPCS,OUTPATIENT,,,580,348,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,433.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6590.94,8242,
Drain bl w/cath insertion,4501860,CDM,981,RC,51102,HCPCS,OUTPATIENT,,,610,366,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,382.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,134.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6591.94,8243,
BLDR IRRIGATION SMPL LAVAGE /INSTLJ,4501878,CDM,981,RC,51700,HCPCS,OUTPATIENT,,,95,57,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,28.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6592.94,8244,
Insert bladder catheter,4501880,CDM,981,RC,51701,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.37,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6593.94,8245,
Insert temp bladder cath,4501900,CDM,981,RC,51702,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6594.94,8246,
Insert bladder cath complex,4501920,CDM,981,RC,51703,HCPCS,OUTPATIENT,,,370,222,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,218.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6595.94,8247,
Change of bladder tube,4501940,CDM,981,RC,51705,HCPCS,OUTPATIENT,,,240,144,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6596.94,8248,
MEAS POST-VOIDING RESIDUAL URINE/BLADDER CAP,4501948,CDM,981,RC,51798,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,19.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,9.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6597.94,8249,
Treatment of penis lesion,4501950,CDM,981,RC,54220,HCPCS,OUTPATIENT,,,510,306,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,357.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,128.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6598.94,8250,
I  d of vulva/perineum,4501960,CDM,981,RC,56405,HCPCS,OUTPATIENT,,,340,204,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,119.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6599.94,8251,
Drainage of gland abscess,4501980,CDM,981,RC,56420,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,104.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6600.94,8252,
INTRO ANY HEMO AGENT/PACK VAG HEMRRG PROF,4501985,CDM,981,RC,57180,HCPCS,OUTPATIENT,,,345,207,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,234.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,114.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6601.94,8253,
UNLISTED PX FEMALE GENITAL SYSTEM NONOBSTETRICAL,4501990,CDM,981,RC,58999,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6602.94,8254,
Vaginal Delivery,4502000,CDM,981,RC,59410,HCPCS,OUTPATIENT,,,2400,1440,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1343.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1035.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6603.94,8255,
PROF ANTEPARTUM CARE ONLY 7+ VISITS,4502006,CDM,981,RC,59426,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,908.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,764.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6604.94,8256,
Spinal fluid tap diagnostic,4502020,CDM,981,RC,62270,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,235.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6605.94,8257,
NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH,4502030,CDM,981,RC,64400,HCPCS,OUTPATIENT,,,320,192,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,210.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6606.94,8258,
N block other peripheral,4502040,CDM,981,RC,64450,HCPCS,OUTPATIENT,,,210,126,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,118.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6607.94,8259,
Remove foreign body from eye,4502060,CDM,981,RC,65205,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,66.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,27.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6608.94,8260,
Remove foreign body from eye,4502080,CDM,981,RC,65220,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,86.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6609.94,8261,
Clear outer ear canal,4502100,CDM,981,RC,69200,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6610.94,8262,
REMOVAL IMPACT CERUM 69209,4502119,CDM,981,RC,69209,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6611.94,8263,
Remove impacted ear wax uni,4502120,CDM,981,RC,69210,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6612.94,8264,
Heart/lung resuscitation cpr,4502140,CDM,981,RC,92950,HCPCS,OUTPATIENT,,,880,528,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,549.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6613.94,8265,
Temporary external pacing,4502160,CDM,981,RC,92953,HCPCS,OUTPATIENT,,,10,6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6614.94,8266,
Cardioversion electric ext,4502180,CDM,981,RC,92960,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,277,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,101.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6615.94,8267,
ECHO TTE F/U OR LIMITED PROF,4502185,CDM,981,RC,93308,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,164.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,65.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6616.94,8268,
CANALITH REPOSITIONING PROC PRO FEE,4502190,CDM,981,RC,95992,HCPCS,OUTPATIENT,,,108,64.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,34.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6617.94,8269,
97605 NEG PRESS WOUND TX < 50 CM PROF,4502200,CDM,981,RC,97605,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6618.94,8270,
US Abdl Aorta Screen AAA ED Prof,4502250,CDM,981,RC,76706,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,141.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6619.94,8271,
ECHO DOPPLER FETAL PW/CW CMPLT PROF,4502267,CDM,981,RC,76827,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,94.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6620.94,8272,
35201 REPAIR BLOOD VESSEL DIRECT NECK PRO FEE,4502281,CDM,981,RC,35201,HCPCS,OUTPATIENT,,,1945,1167,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1671.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,880.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6621.94,8273,
99221 Initial Inpt/Obsv Care (40 minutes),4520221,CDM,987,RC,99221,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,104.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6622.94,8274,
99222 Initial Inpt/Obsv Care (55 minutes),4520222,CDM,987,RC,99222,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6623.94,8275,
99223 Initial Inpt/Obsv Care (75 minutes),4520223,CDM,987,RC,99223,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6624.94,8276,
99231 Subsequent Inpt/Obsv Care (25 minutes),4520231,CDM,987,RC,99231,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6625.94,8277,
99232 Subsequent Inpt/Obsv Care (35 minutes),4520232,CDM,987,RC,99232,HCPCS,OUTPATIENT,,,210,126,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,74.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6626.94,8278,
99233 Subsequent Inpt/Obsv Care (50 minutes),4520233,CDM,987,RC,99233,HCPCS,OUTPATIENT,,,303,181.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,106.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6627.94,8279,
99234 Inpt/Obsv Same Day (45 minutes),4520234,CDM,987,RC,99234,HCPCS,OUTPATIENT,,,394,236.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,136.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,93.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6628.94,8280,
99235 Inpt/Obsv Same Day (70 minutes),4520235,CDM,987,RC,99235,HCPCS,OUTPATIENT,,,493,295.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,151.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6629.94,8281,
99236 Inpt/Obsv Same Day (85 minutes),4520236,CDM,987,RC,99236,HCPCS,OUTPATIENT,,,637,382.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,222.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,198.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6630.94,8282,
99238 INPT/OBSV Discharge <=30 Minutes,4520238,CDM,987,RC,99238,HCPCS,OUTPATIENT,,,210,126,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,74.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6631.94,8283,
99239 INPT/OBSV Discharge >30 Minutes,4520239,CDM,987,RC,99239,HCPCS,OUTPATIENT,,,310,186,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6632.94,8284,
99242 OFFICE/OP NEW/EST CONSULT LEVEL 2,4520242,CDM,987,RC,99242,HCPCS,OUTPATIENT,,,206,123.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6633.94,8285,
99243 OFFICE/OP NEW/EST CONSULT LEVEL 3,4520243,CDM,987,RC,99243,HCPCS,OUTPATIENT,,,288,172.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,84.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6634.94,8286,
99244 OFFICE/OP NEW/EST CONSULT LEVEL 4,4520244,CDM,987,RC,99244,HCPCS,OUTPATIENT,,,456,273.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.91,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6635.94,8287,
99245 OFFICE/OP NEW/EST CONSULT LEVEL 5,4520245,CDM,987,RC,99245,HCPCS,OUTPATIENT,,,654,392.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,208.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,172.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6636.94,8288,
PROF APPLICATION SHORT LEG SPLINT,4520250,CDM,987,RC,29515,HCPCS,OUTPATIENT,,,206,123.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,106.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6637.94,8289,
99252 INPT/OBSV CONSULT LEVEL 2,4520252,CDM,987,RC,99252,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,67.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6638.94,8290,
99253 INPT/OBSV CONSULT LEVEL 3,4520253,CDM,987,RC,99253,HCPCS,OUTPATIENT,,,225,135,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,118.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,94.91,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6639.94,8291,
99254 INPT/OBSV CONSULT LEVEL 4,4520254,CDM,987,RC,99254,HCPCS,OUTPATIENT,,,330,198,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,171.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6640.94,8292,
99255 INPT/OBSV CONSULT LEVEL 5,4520255,CDM,987,RC,99255,HCPCS,OUTPATIENT,,,591,354.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,206.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6641.94,8293,
99281 ED VISIT LEVEL 1 Professional,4520260,CDM,987,RC,99281,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6642.94,8294,
99282 ED VISIT LEVEL 2 Professional,4520268,CDM,987,RC,99282,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6643.94,8295,
99283 ED VISIT LEVEL 3 Professional,4520272,CDM,987,RC,99283,HCPCS,OUTPATIENT,,,188,112.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,68.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6644.94,8296,
ED VISIT LEVEL 4 Professional,4520276,CDM,987,RC,99284,HCPCS,OUTPATIENT,,,356,213.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6645.94,8297,
99285 ED VISIT Professional,4520283,CDM,987,RC,99285,HCPCS,OUTPATIENT,,,526,315.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,193.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,168.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6646.94,8298,
99292 CRITICAL CARE ADDL 30 MIN,4520285,CDM,987,RC,99292,HCPCS,OUTPATIENT,,,337,202.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,102.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6647.94,8299,
99291 CRITICAL CARE 30 TO 74 MIN CHARGE,4520291,CDM,987,RC,99291,HCPCS,OUTPATIENT,,,655,393,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,280.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,203.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6648.94,8300,
12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,4520293,CDM,987,RC,12011,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,117.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6649.94,8301,
29550 STRAPPING OF TOES,4520295,CDM,987,RC,29550,HCPCS,OUTPATIENT,,,36,21.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,29.17,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,10.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6650.94,8302,
10061 ID OF ABCESS COMPLICATED,4520296,CDM,521,RC,10061,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,960.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,960.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,114,38,,91.2,percent of total billed charges,38% of total billed charges,120,40,,96,percent of total billed charges,40% of total billed charges,6651.94,8303,
43753 TX GASTRO INTUB W/ASP,4520298,CDM,987,RC,43753,HCPCS,OUTPATIENT,,,68,40.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6652.94,8304,
12001 RPR S/N/AX/GEN/TRNK 2.5CM/<,4520300,CDM,987,RC,12001,HCPCS,OUTPATIENT,,,137,82.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6653.94,8305,
16000  INITIAL TX 1ST DEGREE BURN LOCAL TX,4520301,CDM,987,RC,16000,HCPCS,OUTPATIENT,,,460,276,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6654.94,8306,
29530 STRAPPING OF KNEE,4520303,CDM,987,RC,29530,HCPCS,OUTPATIENT,,,164,98.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,17.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6655.94,8307,
99307 SUBSQ NURSING FACILITY CARE LEVEL 1,4520307,CDM,987,RC,99307,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6656.94,8308,
99308 SUBSQ NURSING FACILITY CARE LEVEL 2,4520308,CDM,987,RC,99308,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6657.94,8309,
99309 SUBSQ NURSING FACILITY CARE LEVEL 3,4520309,CDM,987,RC,99309,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,101.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6658.94,8310,
99310 SUBSQ NURSING FACILITY CARE LEVEL 4,4520310,CDM,987,RC,99310,HCPCS,OUTPATIENT,,,390,234,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6659.94,8311,
99315 NURSING FACILITY DSCHG <=30 MIN,4520315,CDM,987,RC,99315,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,74.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6660.94,8312,
99316 NURSING FACILITY DSCHG >30 MIN,4520316,CDM,987,RC,99316,HCPCS,OUTPATIENT,,,290,174,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6661.94,8313,
99418 Inpt/Obsv Prolonged Service Addl 15 Minutes,4520318,CDM,987,RC,99418,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6662.94,8314,
ID OF ABSCESS SIMPLE,4520320,CDM,987,RC,10060,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6663.94,8315,
43762 REPLACEMENT OF GASTROSTOMY TUBE,4520325,CDM,987,RC,43762,HCPCS,OUTPATIENT,,,157,94.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,319.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6664.94,8316,
62270 SPINAL FLUID TAP DIAGNOSTIC,4520337,CDM,987,RC,62270,HCPCS,OUTPATIENT,,,242,145.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,235.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6665.94,8317,
99497 Advncd care plan 30 min,4520339,CDM,987,RC,99497,HCPCS,OUTPATIENT,,,234,140.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6666.94,8318,
99498 Advncd care plan addl 30 min,4520340,CDM,987,RC,99498,HCPCS,OUTPATIENT,,,218,130.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,67.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6667.94,8319,
96523 IRRIGATIONOFIMPLVENOUSACCESSDEVICE,4520341,CDM,987,RC,96523,HCPCS,OUTPATIENT,,,68,40.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,22.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6668.94,8320,
US Guided Abd Paracentesis,4520342,CDM,987,RC,49083,HCPCS,OUTPATIENT,,,340,204,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,433.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6669.94,8321,
PF 49083 ABD PARACENTESIS W/IMAGING,4520342,CDM,987,RC,49083,HCPCS,OUTPATIENT,,,340,204,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,433.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6670.94,8322,
ARTHROCENTESIS ASPIR/INJECTION MAJOR JT/BURSA,4520345,CDM,761,RC,20610,HCPCS,OUTPATIENT,,,693,415.8,,589.05,85,,471.24,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,243.59,35.15,,,fee schedule,35.15% of LA custom fee schedule,221.41,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,221.41,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6671.94,8323,
PROF ARTHROCENTESIS ASPIR/INJECTION MAJOR JT/BURSA,4520346,CDM,987,RC,20610,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6672.94,8324,
36573 PROF INSERTION PICC 5YR+ W/ IMAGING,4520347,CDM,987,RC,36573,HCPCS,OUTPATIENT,,,1100,660,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,623.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6673.94,8325,
36573 PROF Insertion PICC line >5,4520347,CDM,987,RC,36573,HCPCS,OUTPATIENT,,,1100,660,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,623.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6674.94,8326,
36584 PROF REPLACEMENT PICC W/IMAGING,4520350,CDM,987,RC,36584,HCPCS,OUTPATIENT,,,956,573.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,305.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6675.94,8327,
36593 PROF DECLOT VASCULAR DEVICE,4520355,CDM,987,RC,36593,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6676.94,8328,
27752 PROF TREATMENT OF TIBIA FRACTURE,4520358,CDM,987,RC,27752,HCPCS,OUTPATIENT,,,1500,900,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,821.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,469.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6677.94,8329,
36410 PROF Non-routine bl draw 3/> yrs,4520360,CDM,987,RC,36410,HCPCS,OUTPATIENT,,,29,17.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,28.25,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6678.94,8330,
37799 PROF VASCULAR SURGERY PROCEDURE UNLISTED,4520379,CDM,987,RC,37799,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6679.94,8331,
76937 PROF US VASC ACCESS PLACEMENT,4520387,CDM,987,RC,76937,HCPCS,OUTPATIENT,,,73,43.8,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6680.94,8332,
Dressing Change FMC,4540894,CDM,272,RC,A4461,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,12.5,50,,10,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,12.5,50,,10,percent of total billed charges,50% of total billed charges,8.79,35.15,,7.032,percent of total billed charges,35.15% of total billed charges,1.99,31.95,,1.592,percent of total billed charges,31.95% of total billed charges,4.5,100,,,fee schedule,100% of CMS custom fee schedule,9.5,38,,7.6,percent of total billed charges,38% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,6681.94,8333,
Left Without Being Seen,4540944,CDM,450,RC,99281,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,249.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.58,35.15,,,fee schedule,35.15% of LA custom fee schedule,15.98,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,150,38,,120,percent of total billed charges,38% of total billed charges,15.98,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6682.94,8334,
99211 Established Visit  Level 1 ED,4540950,CDM,510,RC,99211,HCPCS,OUTPATIENT,,,171,102.6,,145.35,85,,116.28,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,,fee schedule,110% of LA custom fee schedule,32.87,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,64.98,38,,51.984,percent of total billed charges,38% of total billed charges,32.87,100,,,Fee Schedule,100% of LA custom fee schedule,6683.94,8335,
BHRT ECF FEMALE,5000001,CDM,969,RC,SS802,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6684.94,8336,
BHRT PT FEMALE,5000003,CDM,969,RC,SS802,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6685.94,8337,
BHRT ECF MALE T200,5000004,CDM,969,RC,SS801,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6686.94,8338,
BHRT PT MALE T200,5000006,CDM,969,RC,SS801,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6687.94,8339,
Insertion of Implanon Drug D,5000013,CDM,521,RC,11981,HCPCS,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,50.92,38,,40.736,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,6688.94,8340,
Insertion of Implanon Drug D,5000013,CDM,521,RC,11981,HCPCS,OUTPATIENT,,,134,80.4,,113.9,85,,91.12,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,42.81,31.95,,34.248,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,50.92,38,,40.736,percent of total billed charges,38% of total billed charges,53.6,40,,42.88,percent of total billed charges,40% of total billed charges,6689.94,8341,
Removal Implanon,5000015,CDM,521,RC,11982,HCPCS,OUTPATIENT,,,157,94.2,,133.45,85,,106.76,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,50.16,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,50.16,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,59.66,38,,47.728,percent of total billed charges,38% of total billed charges,62.8,40,,50.24,percent of total billed charges,40% of total billed charges,6690.94,8342,
Removal Implanon,5000015,CDM,521,RC,11982,HCPCS,OUTPATIENT,,,157,94.2,,133.45,85,,106.76,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,50.16,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,50.16,31.95,,40.128,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,59.66,38,,47.728,percent of total billed charges,38% of total billed charges,62.8,40,,50.24,percent of total billed charges,40% of total billed charges,6691.94,8343,
69200 PF RMVL FB XTRNL AUDITORY CANAL W/O ANES,5000016,CDM,521,RC,69200,HCPCS,OUTPATIENT,,,107,64.2,,90.95,85,,72.76,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,34.19,31.95,,27.352,percent of total billed charges,31.95% of total billed charges,34.19,31.95,,27.352,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,40.66,38,,32.528,percent of total billed charges,38% of total billed charges,42.8,40,,34.24,percent of total billed charges,40% of total billed charges,6692.94,8344,
"Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.6 to",5000017,CDM,521,RC,11306,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,51.072,percent of total billed charges,38% of total billed charges,67.2,40,,53.76,percent of total billed charges,40% of total billed charges,6693.94,8345,
"Repair Simple  Face, Ears, Eyelids, Nose, Lips and/or Mucous Membranes; 20.1 cm",5000018,CDM,521,RC,12017,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,115,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115,50,,92,percent of total billed charges,50% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,92,40,,73.6,percent of total billed charges,40% of total billed charges,6694.94,8346,
Ventilator Services Initial,5000020,CDM,410,RC,94002,HCPCS,OUTPATIENT,,,1048,628.8,,890.8,85,,712.64,Percent of total billed charges,85% of total billed charges,451.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,451.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,368.37,35.15,,,fee schedule,35.15% of LA custom fee schedule,334.84,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,,case rate,pays based on per visit rate,334.84,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6695.94,8347,
RT Ventilator Services - Subsequent Charge,5000022,CDM,410,RC,94003,HCPCS,OUTPATIENT,,,1048,628.8,,890.8,85,,712.64,Percent of total billed charges,85% of total billed charges,451.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,451.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,368.37,35.15,,,fee schedule,35.15% of LA custom fee schedule,334.84,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,140,100,,,case rate,pays based on per visit rate,334.84,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6696.94,8348,
Visit to determ ldct elig,5000025,CDM,521,RC,G0296,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,6697.94,8349,
Lung Cancer Screening,5000025,CDM,521,RC,G0296,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,6698.94,8350,
BHRT ECF MALE T100,5000026,CDM,969,RC,SS818,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6699.94,8351,
BHRT PT MALE T100,5000028,CDM,969,RC,SS818,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6700.94,8352,
SPA SHAVING ADD ON FEE,5000030,CDM,969,RC,SS002,HCPCS,OUTPATIENT,,,50,30,,,,,,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,6701.94,8353,
G0008 Admin Influenza Virus Vaccine POC,5000031,CDM,771,RC,G0008,HCPCS,OUTPATIENT,,,59,35.4,59,50.15,85,,40.12,Percent of total billed charges,85% of total billed charges,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,29.5,50,,23.6,percent of total billed charges,50% of total billed charges,18.85,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,18.85,31.95,,15.08,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,23.6,40,,18.88,percent of total billed charges,40% of total billed charges,6702.94,8354,
Admin of Pneumococcal Immunization,5000032,CDM,771,RC,G0009,HCPCS,OUTPATIENT,,,88,52.8,59,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,44,50,,35.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,44,50,,35.2,percent of total billed charges,50% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,35.2,40,,28.16,percent of total billed charges,40% of total billed charges,6703.94,8355,
V-ST 1 FACE FOREHEAD,5000033,CDM,969,RC,SS033,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6704.94,8356,
V-ST 1 FACE EYES,5000034,CDM,969,RC,SS034,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6705.94,8357,
V-ST 1 FACE EYES/FOREHEAD,5000035,CDM,969,RC,SS035,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6706.94,8358,
V-ST 1 FACE LOWER FACE,5000036,CDM,969,RC,SS036,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6707.94,8359,
V-ST 1 FACE FULL FACE,5000037,CDM,969,RC,SS037,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6708.94,8360,
V-ST 1 FACE NASOLABIAL LINES,5000038,CDM,969,RC,SS038,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6709.94,8361,
V-ST 1 UPPER TORSO NECK,5000039,CDM,969,RC,SS039,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6710.94,8362,
V-ST 1 UPPER TORSO DECOLLETE,5000040,CDM,969,RC,SS040,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6711.94,8363,
V-ST 1 UPPER TORSO SCARS,5000041,CDM,969,RC,SS041,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6712.94,8364,
V-ST 1 UPPER TORSO STRETCH MARKS,5000042,CDM,969,RC,SS042,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6713.94,8365,
V-ST 1 LOWER TORSO SCARS,5000043,CDM,969,RC,SS043,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6714.94,8366,
BOTOX UNITS,5000044,CDM,969,RC,SS391,HCPCS,OUTPATIENT,,,12,7.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6715.94,8367,
V-ST 1 LOWER TORSO STRETCH MARKS,5000045,CDM,969,RC,SS045,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6716.94,8368,
V-ST 1 LOWER TORSO LABIA MAJORA,5000046,CDM,969,RC,SS046,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6717.94,8369,
V-ST 1 LOWER TORSO LABIA MINORA,5000046,CDM,969,RC,SS046,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6718.94,8370,
Cervical/Vaginal CA Screen; Pelvic/Breast Exam Medicare Charge,5000048,CDM,521,RC,G0101,HCPCS,OUTPATIENT,,,152,91.2,,129.2,85,,103.36,Percent of total billed charges,85% of total billed charges,76,50,,60.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,76,50,,60.8,percent of total billed charges,50% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,57.76,38,,46.208,percent of total billed charges,38% of total billed charges,60.8,40,,48.64,percent of total billed charges,40% of total billed charges,6719.94,8371,
V-ST 1 LOWER TORSO LABIA MAJORA/MINORA,5000049,CDM,969,RC,SS049,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6720.94,8372,
V-ST 1 LIMBS ELBOWS,5000050,CDM,969,RC,SS050,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6721.94,8373,
V-ST 1 LIMBS HANDS,5000051,CDM,969,RC,SS051,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6722.94,8374,
V-ST 1 LIMBS HANDS/FINGERS,5000052,CDM,969,RC,SS052,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6723.94,8375,
V-ST 1 LIMBS KNEES,5000053,CDM,969,RC,SS053,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6724.94,8376,
"Diphtheria, tetanus toxoids, and acellular pertussis vaccine, haemophilus influe",5000054,CDM,521,RC,90698,HCPCS,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,172.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,172.35,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,46,40,,36.8,percent of total billed charges,40% of total billed charges,6725.94,8377,
90700 DTaP VACCINE,5000055,CDM,521,RC,90700,HCPCS,OUTPATIENT,,,149,89.4,,126.65,85,,101.32,Percent of total billed charges,85% of total billed charges,43.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,43.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,56.62,38,,45.296,percent of total billed charges,38% of total billed charges,59.6,40,,47.68,percent of total billed charges,40% of total billed charges,6726.94,8378,
90702 Diphtheria and tetanus toxoid,5000056,CDM,521,RC,90702,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,97.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,97.74,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.78,40,,3.024,percent of total billed charges,40% of total billed charges,6727.94,8379,
90723 Dtap-HepB-IPV Vaccine,5000058,CDM,521,RC,90723,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,143.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,143.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,51.12,31.95,,40.896,percent of total billed charges,31.95% of total billed charges,51.12,31.95,,40.896,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,60.8,38,,48.64,percent of total billed charges,38% of total billed charges,64,40,,51.2,percent of total billed charges,40% of total billed charges,6728.94,8380,
90696 DTaP-IPV Virus Vaccine,5000059,CDM,636,RC,90696,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,91.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,91.7,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,2.656,percent of total billed charges,35.15% of total billed charges,2.56,31.95,,2.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,6729.94,8381,
99316 NURSING FACILITY DSCHG >30 MIN,5000060,CDM,521,RC,99316,HCPCS,OUTPATIENT,,,290,174,,246.5,85,,197.2,Percent of total billed charges,85% of total billed charges,145,50,,116,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,145,50,,116,percent of total billed charges,50% of total billed charges,92.66,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,92.66,31.95,,74.128,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,110.2,38,,88.16,percent of total billed charges,38% of total billed charges,116,40,,92.8,percent of total billed charges,40% of total billed charges,6730.94,8382,
99315 NURSING FACILITY DSCHG <=30 MIN,5000061,CDM,521,RC,99315,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,76,38,,60.8,percent of total billed charges,38% of total billed charges,80,40,,64,percent of total billed charges,40% of total billed charges,6731.94,8383,
Etonogestrel Implant (INexplanon),5000062,CDM,636,RC,J7307,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,1611.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1611.72,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,56.24,percent of total billed charges,35.15% of total billed charges,2.66,31.95,,2.128,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,6732.94,8384,
V-IPL 1 SKIN REJUV FULL FACE,5000063,CDM,969,RC,SS063,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6733.94,8385,
V-IPL 1 SKIN REJUV LOWER FACE,5000064,CDM,969,RC,SS064,HCPCS,OUTPATIENT,,,150,90,,,,,,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,6734.94,8386,
V-IPL 1 SKIN REJUV NECK,5000065,CDM,969,RC,SS065,HCPCS,OUTPATIENT,,,150,90,,,,,,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,6735.94,8387,
V-IPL 1 SKIN REJUV FULL FACE  and NECK,5000066,CDM,969,RC,SS066,HCPCS,OUTPATIENT,,,225,135,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6736.94,8388,
V-IPL 1 PIGMENTATION LENTIGINES,5000067,CDM,969,RC,SS067,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6737.94,8389,
V-IPL 1 PIGMENTATION AGE SPOTS,5000068,CDM,969,RC,SS068,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6738.94,8390,
V-IPL 1 PIGMENTATION FRECKLES,5000069,CDM,969,RC,SS069,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6739.94,8391,
V-IPL 1 PIGMENTATION SOLAR LENTIGO,5000070,CDM,969,RC,SS070,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6740.94,8392,
"Influenza virus vaccine, live, for intranasal use",5000071,CDM,521,RC,90660,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,32.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,32.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.78,40,,3.024,percent of total billed charges,40% of total billed charges,6741.94,8393,
Flu Vaccine Split 6-35 Months IM POC,5000072,CDM,636,RC,90657,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,8.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,8.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,,fee schedule,35.15% of LA custom fee schedule,3.02,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,33.05,100,,,case rate,pays based on per visit rate,3.02,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6742.94,8394,
Flu Vaccine Split 3 yrs and Above IM POC,5000073,CDM,521,RC,90658,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,24.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,6743.94,8395,
V-IPL 1 PIGMENTATION KERATOSIS,5000074,CDM,969,RC,SS074,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6744.94,8396,
V-IPL 1 PIGMENTATION CAFE-AU-LAIT,5000075,CDM,969,RC,SS075,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6745.94,8397,
V-IPL 1 PIGMENTATION MELASMA,5000076,CDM,969,RC,SS076,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6746.94,8398,
V-IPL 1 PIGMENTATION HEMOSIDERIN,5000077,CDM,969,RC,SS077,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6747.94,8399,
V-IPL 1 PIGMENTATION POIKILODERMA,5000078,CDM,969,RC,SS078,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6748.94,8400,
V-IPL 1 PIGMENTATION BRECKER NEVUS,5000079,CDM,969,RC,SS079,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6749.94,8401,
PRISTINE SINGLE,5000080,CDM,969,RC,SS080,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6750.94,8402,
PRISTINE ADD ON,5000081,CDM,969,RC,SS081,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6751.94,8403,
90470 H1N1 Immunization Administration,5000082,CDM,521,RC,90470,HCPCS,OUTPATIENT,,,15.22,9.132,,12.94,85,,10.352,Percent of total billed charges,85% of total billed charges,7.61,50,,6.088,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,7.61,50,,6.088,percent of total billed charges,50% of total billed charges,4.86,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,4.86,31.95,,3.888,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,5.78,38,,4.624,percent of total billed charges,38% of total billed charges,6.09,40,,4.872,percent of total billed charges,40% of total billed charges,6752.94,8404,
V-IPL 1 VASC LESIONS FACIAL TELANGIECTASIA,5000083,CDM,969,RC,SS083,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6753.94,8405,
V-IPL 1 VASC LESIONS ERYTHEMA OF ROSACEA,5000084,CDM,969,RC,SS084,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6754.94,8406,
V-IPL 1 VASC LESIONS HEMANGIOMA,5000085,CDM,969,RC,SS085,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6755.94,8407,
V-IPL 1 VASC LESIONS PORT WINE STAIN,5000086,CDM,969,RC,SS086,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6756.94,8408,
"90746 Hepatitis B vaccine, adult dosage (3 dose schedule)",5000087,CDM,636,RC,90746,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,105.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,105.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,,fee schedule,35.15% of LA custom fee schedule,3.02,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,175.95,100,,,case rate,pays based on per visit rate,3.02,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6757.94,8409,
"Hepatitis B  Hemophilus influenza b vaccine (HepB-Hib), IM use POC",5000088,CDM,521,RC,90748,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,65.5,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,65.5,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.78,40,,3.024,percent of total billed charges,40% of total billed charges,6758.94,8410,
Hepatitis A Adult Vaccine POC,5000089,CDM,521,RC,90632,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,105.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,105.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.78,40,,3.024,percent of total billed charges,40% of total billed charges,6759.94,8411,
Hepatitis A Peds/Adol Vaccine 2 Dose Sched Charge,5000090,CDM,636,RC,90633,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,57.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,57.3,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.85,35.15,,,fee schedule,35.15% of LA custom fee schedule,20.77,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20.77,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6760.94,8412,
"Hepatitis A vaccine, pediatric/adolescent dosage-3 dose",5000091,CDM,521,RC,90634,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,35.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,35.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,26,40,,20.8,percent of total billed charges,40% of total billed charges,6761.94,8413,
Home Visit Level 2 Established - 99348,5000092,CDM,521,RC,99348,HCPCS,OUTPATIENT,,,163,97.8,,138.55,85,,110.84,Percent of total billed charges,85% of total billed charges,81.5,50,,65.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,81.5,50,,65.2,percent of total billed charges,50% of total billed charges,52.08,31.95,,41.664,percent of total billed charges,31.95% of total billed charges,52.08,31.95,,41.664,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,61.94,38,,49.552,percent of total billed charges,38% of total billed charges,65.2,40,,52.16,percent of total billed charges,40% of total billed charges,6762.94,8414,
Human Papilloma virus (HPV) Vaccine POC,5000093,CDM,636,RC,90649,HCPCS,OUTPATIENT,,,310,186,,263.5,85,,210.8,Percent of total billed charges,85% of total billed charges,249.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,249.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.97,35.15,,,fee schedule,35.15% of LA custom fee schedule,99.05,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.05,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6763.94,8415,
"90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nona",5000094,CDM,521,RC,90651,HCPCS,OUTPATIENT,,,322,193.2,,273.7,85,,218.96,Percent of total billed charges,85% of total billed charges,447.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,447.57,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,102.88,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,102.88,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,122.36,38,,97.888,percent of total billed charges,38% of total billed charges,128.8,40,,103.04,percent of total billed charges,40% of total billed charges,6764.94,8416,
90472 Each additional vaccine,5000095,CDM,771,RC,90472,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,20.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,34,40,,27.2,percent of total billed charges,40% of total billed charges,6765.94,8417,
90472 Each additional vaccine,5000095,CDM,771,RC,90472,HCPCS,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,20.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,20.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,9.6,40,,7.68,percent of total billed charges,40% of total billed charges,6766.94,8418,
90471 Immunization administration; 1 vaccine,5000096,CDM,771,RC,90471,HCPCS,OUTPATIENT,,,132,79.2,,112.2,85,,89.76,Percent of total billed charges,85% of total billed charges,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,42.17,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,42.17,31.95,,33.736,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,52.8,40,,42.24,percent of total billed charges,40% of total billed charges,6767.94,8419,
90471 Immunization administration; 1 vaccine,5000096,CDM,771,RC,90471,HCPCS,OUTPATIENT,,,88,52.8,,74.8,85,,59.84,Percent of total billed charges,85% of total billed charges,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,28.12,31.95,,22.496,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,35.2,40,,28.16,percent of total billed charges,40% of total billed charges,6768.94,8420,
90460 Immunization administration with counseling 1st vaccine,5000097,CDM,771,RC,90460,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,6769.94,8421,
90460 Immunization administration with counseling 1st vaccine,5000097,CDM,771,RC,90460,HCPCS,OUTPATIENT,,,46,27.6,,39.1,85,,31.28,Percent of total billed charges,85% of total billed charges,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,14.7,31.95,,11.76,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,18.4,40,,14.72,percent of total billed charges,40% of total billed charges,6770.94,8422,
90461 Immunization Administration Each Additional,5000098,CDM,771,RC,90461,HCPCS,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,3.42,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.42,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,9.6,40,,7.68,percent of total billed charges,40% of total billed charges,6771.94,8423,
90461 Immunization Administration Each Additional,5000098,CDM,771,RC,90461,HCPCS,OUTPATIENT,,,24,14.4,,20.4,85,,16.32,Percent of total billed charges,85% of total billed charges,3.42,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3.42,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,9.6,40,,7.68,percent of total billed charges,40% of total billed charges,6772.94,8424,
SARS-CoV2 COVID19 w/optic,5000099,CDM,306,RC,87811,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,56.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,56.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,34.14,110,,,fee schedule,110% of LA custom fee schedule,31.04,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,19,38,,15.2,percent of total billed charges,38% of total billed charges,31.04,100,,,Fee Schedule,100% of LA custom fee schedule,6773.94,8425,
"Influenza Virus Vaccine, IM, Fluzone",5000100,CDM,521,RC,Q2038,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,16.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,16.46,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,6774.94,8426,
"90656 Influenza virus vaccine, trivalent, split virus, preservative free, when a",5000101,CDM,521,RC,90656,HCPCS,OUTPATIENT,,,85,51,,,,,,other,Not separately reimbursable,27.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,6775.94,8427,
99306 Initial Nursing Facility Care High 45 min,5000102,CDM,521,RC,99306,HCPCS,OUTPATIENT,,,325,195,,,,,,other,Not separately reimbursable,162.5,50,,130,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,162.5,50,,130,percent of total billed charges,50% of total billed charges,103.84,31.95,,83.072,percent of total billed charges,31.95% of total billed charges,103.84,31.95,,83.072,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,123.5,38,,98.8,percent of total billed charges,38% of total billed charges,130,40,,104,percent of total billed charges,40% of total billed charges,6776.94,8428,
99305 Initial Nursing Facility Care Mod 35 min,5000103,CDM,521,RC,99305,HCPCS,OUTPATIENT,,,257,154.2,,,,,,other,Not separately reimbursable,128.5,50,,102.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,128.5,50,,102.8,percent of total billed charges,50% of total billed charges,82.11,31.95,,65.688,percent of total billed charges,31.95% of total billed charges,82.11,31.95,,65.688,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,97.66,38,,78.128,percent of total billed charges,38% of total billed charges,102.8,40,,82.24,percent of total billed charges,40% of total billed charges,6777.94,8429,
"Annual Wellness Visit, Initial (AWV)",5000104,CDM,521,RC,G0438,HCPCS,OUTPATIENT,,,322,193.2,,,,,,other,Not separately reimbursable,161,50,,128.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,161,50,,128.8,percent of total billed charges,50% of total billed charges,102.88,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,102.88,31.95,,82.304,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,122.36,38,,97.888,percent of total billed charges,38% of total billed charges,128.8,40,,103.04,percent of total billed charges,40% of total billed charges,6778.94,8430,
Preventive Medicine 65+ years New - 99387,5000105,CDM,521,RC,99387,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,6779.94,8431,
Preventive Medicine 40-64 years New - 99386,5000106,CDM,521,RC,99386,HCPCS,OUTPATIENT,,,234,140.4,,,,,,other,Not separately reimbursable,117,50,,93.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,117,50,,93.6,percent of total billed charges,50% of total billed charges,74.76,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,74.76,31.95,,59.808,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,88.92,38,,71.136,percent of total billed charges,38% of total billed charges,93.6,40,,74.88,percent of total billed charges,40% of total billed charges,6780.94,8432,
Preventive Medicine 12-17 years New - 99384,5000107,CDM,521,RC,99384,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,50,50,,40,percent of total billed charges,50% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,6781.94,8433,
Preventive Medicine 1-4 years New - 99382,5000108,CDM,521,RC,99382,HCPCS,OUTPATIENT,,,161,96.6,,,,,,other,Not separately reimbursable,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,80.5,50,,64.4,percent of total billed charges,50% of total billed charges,51.44,31.95,,41.152,percent of total billed charges,31.95% of total billed charges,51.44,31.95,,41.152,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,61.18,38,,48.944,percent of total billed charges,38% of total billed charges,64.4,40,,51.52,percent of total billed charges,40% of total billed charges,6782.94,8434,
Preventive Medicine 18-39 years New - 99385,5000109,CDM,521,RC,99385,HCPCS,OUTPATIENT,,,193,115.8,,,,,,other,Not separately reimbursable,96.5,50,,77.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,96.5,50,,77.2,percent of total billed charges,50% of total billed charges,61.66,31.95,,49.328,percent of total billed charges,31.95% of total billed charges,61.66,31.95,,49.328,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,73.34,38,,58.672,percent of total billed charges,38% of total billed charges,77.2,40,,61.76,percent of total billed charges,40% of total billed charges,6783.94,8435,
Preventive Medicine 5-11 years New - 99383,5000110,CDM,521,RC,99383,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,64.6,38,,51.68,percent of total billed charges,38% of total billed charges,68,40,,54.4,percent of total billed charges,40% of total billed charges,6784.94,8436,
Preventive Medicine < 1 year New - 99381,5000111,CDM,521,RC,99381,HCPCS,OUTPATIENT,,,152,91.2,,,,,,other,Not separately reimbursable,76,50,,60.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,76,50,,60.8,percent of total billed charges,50% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,57.76,38,,46.208,percent of total billed charges,38% of total billed charges,60.8,40,,48.64,percent of total billed charges,40% of total billed charges,6785.94,8437,
Betamethasone acetsod phosp,5000112,CDM,636,RC,J0702,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,9.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,9.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.03,35.15,,5.624,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6786.94,8438,
"J0945 Injection, brompheniramine maleate, per 10 mg",5000113,CDM,636,RC,J0945,HCPCS,OUTPATIENT,,,10,6,,,,,,other,Not separately reimbursable,1.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.13,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,6787.94,8439,
"Injection, Ceftriaxone Sodium, Per 250 MG Charge",5000114,CDM,636,RC,J0696,HCPCS,OUTPATIENT,,,21.25,12.75,,,,,,other,Not separately reimbursable,0.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.71,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.47,35.15,,,fee schedule,35.15% of LA custom fee schedule,6.79,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.79,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6788.94,8440,
"INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG",5000115,CDM,636,RC,J0735,HCPCS,OUTPATIENT,,,41,24.6,,,,,,other,Not separately reimbursable,29.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.41,35.15,,11.528,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,13.1,31.95,,10.48,percent of total billed charges,31.95% of total billed charges,6789.94,8441,
dexamethasone,5000116,CDM,636,RC,J1100,HCPCS,OUTPATIENT,,,5,3,,,,,,other,Not separately reimbursable,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1.76,35.15,,,fee schedule,35.15% of LA custom fee schedule,1.6,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1.6,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6790.94,8442,
"Injection, Dexamethosone Sodium Phosphate Charge",5000116,CDM,636,RC,J1100,HCPCS,OUTPATIENT,,,3,1.8,,,,,,other,Not separately reimbursable,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1.05,35.15,,,fee schedule,35.15% of LA custom fee schedule,0.96,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.96,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6791.94,8443,
"J1100 Injection, dexamethosone sodium phosphate, 1 mg (4mg)",5000116,CDM,636,RC,J1100,HCPCS,OUTPATIENT,,,5,3,,,,,,other,Not separately reimbursable,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.19,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1.76,35.15,,,fee schedule,35.15% of LA custom fee schedule,1.6,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1.6,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6792.94,8444,
DIPHENHYDRAMINE/50MG,5000117,CDM,636,RC,J1200,HCPCS,OUTPATIENT,,,10,6,,,,,,other,Not separately reimbursable,1.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.52,35.15,,,fee schedule,35.15% of LA custom fee schedule,3.2,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.2,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6793.94,8445,
Furosemide Injection 20 mg Charge,5000118,CDM,636,RC,J1940,HCPCS,OUTPATIENT,,,12,7.2,,,,,,other,Not separately reimbursable,0.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,6794.94,8446,
"J3410 Injection, hydroxyzine hcl, up to 25 mg",5000119,CDM,636,RC,J3410,HCPCS,OUTPATIENT,,,12.35,7.41,,,,,,other,Not separately reimbursable,19.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,19.77,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.34,35.15,,3.472,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.95,31.95,,3.16,percent of total billed charges,31.95% of total billed charges,6795.94,8447,
"J1750 Iron Dextran Inj, 50 mg",5000120,CDM,636,RC,J1750,HCPCS,OUTPATIENT,,,24,14.4,,,,,,other,Not separately reimbursable,26.16,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,26.16,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,8.44,35.15,,6.752,percent of total billed charges,35.15% of total billed charges,0.96,31.95,,0.768,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,41.43,100,,,case rate,pays based on per visit rate,7.67,31.95,,6.136,percent of total billed charges,31.95% of total billed charges,6796.94,8448,
"J1815 Injection, insulin, per 5 units",5000121,CDM,636,RC,J1815,HCPCS,OUTPATIENT,,,12,7.2,,,,,,other,Not separately reimbursable,0.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.76,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,,fee schedule,35.15% of LA custom fee schedule,3.83,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.83,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6797.94,8449,
"Injection, Ketorolac Tromethamine Charge",5000122,CDM,636,RC,J1885,HCPCS,OUTPATIENT,,,10,6,,,,,,other,Not separately reimbursable,0.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.92,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,32.63,31.95,,26.104,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,6798.94,8450,
Lidocaine injection,5000123,CDM,983,RC,J2003,HCPCS,OUTPATIENT,,,10,6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6799.94,8451,
J2001 lidocaine 1% Inj 50 ml Sol Charge FMC,5000123,CDM,250,RC,J2003,HCPCS,OUTPATIENT,,,10,6,,,,,,other,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,5,50,,4,percent of total billed charges,50% of total billed charges,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.8,38,,3.04,percent of total billed charges,38% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,6800.94,8452,
Lincomycin injection,5000124,CDM,983,RC,J2010,HCPCS,OUTPATIENT,,,10,6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,10.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,9.35,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6801.94,8453,
"Injection, medroxyprogesterone acetate, 1 mg",5000125,CDM,983,RC,J1050,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6802.94,8454,
Methocarbamol injection,5000126,CDM,983,RC,J2800,HCPCS,OUTPATIENT,,,35,21,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7.25,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6803.94,8455,
Methylprednisolone 40 MG inj,5000127,CDM,983,RC,J1010,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.11,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6804.94,8456,
"Ondansetron Hydrochloride, per 1 mg Injection",5000128,CDM,983,RC,J2405,HCPCS,OUTPATIENT,,,7,4.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.08,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6805.94,8457,
"Penicillin g benzathine inj, 100,000 units",5000129,CDM,983,RC,J0561,HCPCS,OUTPATIENT,,,8,4.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,16.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.36,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6806.94,8458,
"Injection, Promethazine HCL, up to 50 mg Charge",5000130,CDM,983,RC,J2550,HCPCS,OUTPATIENT,,,15,9,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.31,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6807.94,8459,
"Injection, testosterone cypionate 1mg",5000131,CDM,983,RC,J1080,HCPCS,OUTPATIENT,,,96.95,58.17,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6808.94,8460,
Tetanus immune globulin inj,5000133,CDM,983,RC,J1670,HCPCS,OUTPATIENT,,,15,9,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,576.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,581.77,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6809.94,8461,
"Inj, Kenalog, Per 10mg Charge",5000134,CDM,983,RC,J3301,HCPCS,OUTPATIENT,,,45,27,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.9,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6810.94,8462,
J3301 triamcinolone acetonide 40 mg/mL Inj Susp Charge FMC,5000134,CDM,250,RC,J3301,HCPCS,OUTPATIENT,,,45,27,,,,,,other,Not separately reimbursable,1.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.82,35.15,,12.656,percent of total billed charges,35.15% of total billed charges,137.09,31.95,,109.672,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,17.1,38,,13.68,percent of total billed charges,38% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,6811.94,8463,
"J3301 Injection, Kenalog, triamcinolone acetonide, per 10 mg",5000134,CDM,983,RC,J3301,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.9,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6812.94,8464,
"Injection, Vitamin B-12 Cyanocobalamin, up to 1000 mcg Charge",5000135,CDM,983,RC,J3420,HCPCS,OUTPATIENT,,,5,3,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1.14,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6813.94,8465,
Garamycin gentamicin inj,5000136,CDM,983,RC,J1580,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2.74,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6814.94,8466,
"69949  Unlisted procedure, inner ear",5000137,CDM,983,RC,69949,HCPCS,OUTPATIENT,,,169,101.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6815.94,8467,
"Levalbuterol, inhalation solution, non-compounded, unit dose, 0.5 mg",5000138,CDM,983,RC,J7614,HCPCS,OUTPATIENT,,,4,2.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,0.08,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6816.94,8468,
V-IPL 4-6 SKIN REJUV FACE 30 MIN,5000139,CDM,969,RC,SS139,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6817.94,8469,
V-IPL 4-6 SKIN REJUV NECK 20 MIN,5000140,CDM,969,RC,SS140,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6818.94,8470,
V-IPL 4-6 SKIN REJUV FULL FACE  and NECK 60 MIN,5000141,CDM,969,RC,SS141,HCPCS,OUTPATIENT,,,2700,1620,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6819.94,8471,
"90707 Measles, mumps and rubella virus vaccine (MMR)",5000142,CDM,636,RC,90707,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,139.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,139.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,21.09,35.15,,,fee schedule,35.15% of LA custom fee schedule,19.17,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,19.17,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6820.94,8472,
"Measles, mumps, rubella, and varicella vaccine (MMRV)",5000143,CDM,636,RC,90710,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,419.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,419.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.27,35.15,,,fee schedule,35.15% of LA custom fee schedule,57.51,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,400,100,,,case rate,pays based on per visit rate,57.51,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6821.94,8473,
"Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for",5000144,CDM,636,RC,90734,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,231.03,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,231.03,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,91.39,35.15,,,fee schedule,35.15% of LA custom fee schedule,83.07,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,83.07,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6822.94,8474,
Office Consultation Level 2 - 99242,5000147,CDM,510,RC,99242,HCPCS,OUTPATIENT,,,206,123.6,,,,,,other,Not separately reimbursable,103,50,,82.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,103,50,,82.4,percent of total billed charges,50% of total billed charges,65.82,31.95,,52.656,percent of total billed charges,31.95% of total billed charges,65.82,31.95,,52.656,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,78.28,38,,62.624,percent of total billed charges,38% of total billed charges,82.4,40,,65.92,percent of total billed charges,40% of total billed charges,6823.94,8475,
Office Consultation Level 3 - 99243,5000148,CDM,510,RC,99243,HCPCS,OUTPATIENT,,,288,172.8,,,,,,other,Not separately reimbursable,144,50,,115.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,144,50,,115.2,percent of total billed charges,50% of total billed charges,92.02,31.95,,73.616,percent of total billed charges,31.95% of total billed charges,92.02,31.95,,73.616,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,109.44,38,,87.552,percent of total billed charges,38% of total billed charges,115.2,40,,92.16,percent of total billed charges,40% of total billed charges,6824.94,8476,
Office Consultation Level 5 - 99245,5000149,CDM,510,RC,99245,HCPCS,OUTPATIENT,,,566,339.6,,,,,,other,Not separately reimbursable,283,50,,226.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,283,50,,226.4,percent of total billed charges,50% of total billed charges,180.84,31.95,,144.672,percent of total billed charges,31.95% of total billed charges,180.84,31.95,,144.672,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,215.08,38,,172.064,percent of total billed charges,38% of total billed charges,226.4,40,,181.12,percent of total billed charges,40% of total billed charges,6825.94,8477,
Office Consultation Level 4 - 99244,5000150,CDM,510,RC,99244,HCPCS,OUTPATIENT,,,360,216,,,,,,other,Not separately reimbursable,180,50,,144,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,180,50,,144,percent of total billed charges,50% of total billed charges,115.02,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,115.02,31.95,,92.016,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,136.8,38,,109.44,percent of total billed charges,38% of total billed charges,144,40,,115.2,percent of total billed charges,40% of total billed charges,6826.94,8478,
Office/OP New Visit Level 4 99204,5000152,CDM,521,RC,99204,HCPCS,OUTPATIENT,,,255,153,,,,,,other,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,96.9,38,,77.52,percent of total billed charges,38% of total billed charges,102,40,,81.6,percent of total billed charges,40% of total billed charges,6827.94,8479,
Office/OP New Visit Level 3 99203,5000153,CDM,521,RC,99203,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,56.62,38,,45.296,percent of total billed charges,38% of total billed charges,59.6,40,,47.68,percent of total billed charges,40% of total billed charges,6828.94,8480,
Office/OP New Visit Level 2 99202,5000154,CDM,521,RC,99202,HCPCS,OUTPATIENT,,,98,58.8,,,,,,other,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,37.24,38,,29.792,percent of total billed charges,38% of total billed charges,39.2,40,,31.36,percent of total billed charges,40% of total billed charges,6829.94,8481,
Office/OP New Visit Level 5 99205,5000155,CDM,521,RC,99205,HCPCS,OUTPATIENT,,,329,197.4,,,,,,other,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.12,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,105.12,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,125.02,38,,100.016,percent of total billed charges,38% of total billed charges,131.6,40,,105.28,percent of total billed charges,40% of total billed charges,6830.94,8482,
Office/OP Established Visit Level 2 99212,5000156,CDM,521,RC,99212,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,32,40,,25.6,percent of total billed charges,40% of total billed charges,6831.94,8483,
Office/OP Established Visit Level 1 99211,5000157,CDM,521,RC,99211,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,6832.94,8484,
Office/OP Established Visit Level 5 99215,5000158,CDM,521,RC,99215,HCPCS,OUTPATIENT,,,216,129.6,,,,,,other,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,82.08,38,,65.664,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,6833.94,8485,
Office/OP Established Visit Level 4 99214,5000159,CDM,521,RC,99214,HCPCS,OUTPATIENT,,,153,91.8,,,,,,other,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,48.88,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,48.88,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,58.14,38,,46.512,percent of total billed charges,38% of total billed charges,61.2,40,,48.96,percent of total billed charges,40% of total billed charges,6834.94,8486,
Office/OP Established Visit Level 3 99213,5000160,CDM,521,RC,99213,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,6835.94,8487,
Office/OP Established Visit Level 3 99213 NP,5000160,CDM,521,RC,99213,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,6836.94,8488,
Office/OP Est Visit Level 3 99213,5000160,CDM,521,RC,99213,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,6837.94,8489,
Preventive Medicine 65+ years Established - 99397,5000161,CDM,521,RC,99397,HCPCS,OUTPATIENT,,,201,120.6,,,,,,other,Not separately reimbursable,100.5,50,,80.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100.5,50,,80.4,percent of total billed charges,50% of total billed charges,64.22,31.95,,51.376,percent of total billed charges,31.95% of total billed charges,64.22,31.95,,51.376,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,76.38,38,,61.104,percent of total billed charges,38% of total billed charges,80.4,40,,64.32,percent of total billed charges,40% of total billed charges,6838.94,8490,
Preventive Medicine 12-17 years Established - 99394,5000162,CDM,521,RC,99394,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,64.6,38,,51.68,percent of total billed charges,38% of total billed charges,68,40,,54.4,percent of total billed charges,40% of total billed charges,6839.94,8491,
Preventive Medicine 1-4 years Established - 99392,5000163,CDM,521,RC,99392,HCPCS,OUTPATIENT,,,152,91.2,,,,,,other,Not separately reimbursable,76,50,,60.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,76,50,,60.8,percent of total billed charges,50% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,57.76,38,,46.208,percent of total billed charges,38% of total billed charges,60.8,40,,48.64,percent of total billed charges,40% of total billed charges,6840.94,8492,
Preventive Medicine 18-39 years Established - 99395,5000164,CDM,521,RC,99395,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,87.5,50,,70,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.5,50,,70,percent of total billed charges,50% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,66.5,38,,53.2,percent of total billed charges,38% of total billed charges,70,40,,56,percent of total billed charges,40% of total billed charges,6841.94,8493,
Preventive Medicine 40-64 years Established - 99396,5000165,CDM,521,RC,99396,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,95,50,,76,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,95,50,,76,percent of total billed charges,50% of total billed charges,60.71,31.95,,48.568,percent of total billed charges,31.95% of total billed charges,60.71,31.95,,48.568,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,72.2,38,,57.76,percent of total billed charges,38% of total billed charges,76,40,,60.8,percent of total billed charges,40% of total billed charges,6842.94,8494,
Preventive Medicine 5-11 years Established - 99393,5000166,CDM,521,RC,99393,HCPCS,OUTPATIENT,,,152,91.2,,,,,,other,Not separately reimbursable,76,50,,60.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,76,50,,60.8,percent of total billed charges,50% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,57.76,38,,46.208,percent of total billed charges,38% of total billed charges,60.8,40,,48.64,percent of total billed charges,40% of total billed charges,6843.94,8495,
Preventive Medicine < 1 year Established - 99391,5000167,CDM,521,RC,99391,HCPCS,OUTPATIENT,,,138,82.8,,,,,,other,Not separately reimbursable,69,50,,55.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,69,50,,55.2,percent of total billed charges,50% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,44.09,31.95,,35.272,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,52.44,38,,41.952,percent of total billed charges,38% of total billed charges,55.2,40,,44.16,percent of total billed charges,40% of total billed charges,6844.94,8496,
"90732 Pneumococcal polysaccharide vacc, 23-valent, adult/immunosuppressed, 2 yea",5000168,CDM,636,RC,90732,HCPCS,OUTPATIENT,,,156,93.6,,,,,,other,Not separately reimbursable,200.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,200.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.83,35.15,,,fee schedule,35.15% of LA custom fee schedule,49.84,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,333.68,100,,,case rate,pays based on per visit rate,49.84,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6845.94,8497,
"90732 Pneumococcal polysaccharide vacc, 23-valent, adult/immunosuppressed, 2 yea",5000168,CDM,636,RC,90732,HCPCS,OUTPATIENT,,,156,93.6,,,,,,other,Not separately reimbursable,200.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,200.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.83,35.15,,,fee schedule,35.15% of LA custom fee schedule,49.84,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,333.68,100,,,case rate,pays based on per visit rate,49.84,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6846.94,8498,
"Pneumococcal conjugate vaccine, 13 valent, for IM use",5000169,CDM,521,RC,90670,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,387.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,387.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,46,40,,36.8,percent of total billed charges,40% of total billed charges,6847.94,8499,
"Pneumococcal conjugate vaccine, 13 valent, for IM use",5000169,CDM,521,RC,90670,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,387.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,387.66,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,46,40,,36.8,percent of total billed charges,40% of total billed charges,6848.94,8500,
"90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular u",5000171,CDM,521,RC,90713,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,63.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,63.1,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.78,40,,3.024,percent of total billed charges,40% of total billed charges,6849.94,8501,
"Preventive Medicine Counseling And/Or Risk Factor Reduction Intervention(S), Ind",5000173,CDM,521,RC,99403,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,75,50,,60,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,75,50,,60,percent of total billed charges,50% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,57,38,,45.6,percent of total billed charges,38% of total billed charges,60,40,,48,percent of total billed charges,40% of total billed charges,6850.94,8502,
Pure Tone Audiometry(Threshold); Air Only,5000175,CDM,521,RC,92552,HCPCS,OUTPATIENT,,,66,39.6,,,,,,other,Not separately reimbursable,33,50,,26.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,33,50,,26.4,percent of total billed charges,50% of total billed charges,21.09,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,21.09,31.95,,16.872,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,25.08,38,,20.064,percent of total billed charges,38% of total billed charges,26.4,40,,21.12,percent of total billed charges,40% of total billed charges,6851.94,8503,
V-VR MAINTENANCE,5000176,CDM,969,RC,SS006,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6852.94,8504,
V-VR 3,5000177,CDM,969,RC,SS007,HCPCS,OUTPATIENT,,,2800,1680,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6853.94,8505,
"Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use POC",5000178,CDM,521,RC,90680,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,149.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,149.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,64.6,38,,51.68,percent of total billed charges,38% of total billed charges,68,40,,54.4,percent of total billed charges,40% of total billed charges,6854.94,8506,
Screening papanicolaou smear,5000179,CDM,521,RC,Q0091,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,40,50,,32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40,50,,32,percent of total billed charges,50% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,32,40,,25.6,percent of total billed charges,40% of total billed charges,6855.94,8507,
Vision Acuity Screening,5000180,CDM,521,RC,99173,HCPCS,OUTPATIENT,,,6,3.6,,,,,,other,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,6856.94,8508,
"Screening test, pure tone, air only Charge",5000181,CDM,521,RC,92551,HCPCS,OUTPATIENT,,,21,12.6,,,,,,other,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,7.98,38,,6.384,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,6857.94,8509,
V-FORM 6 - 8 ARMS,5000182,CDM,969,RC,SS182,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6858.94,8510,
V-FORM 6 - 8 ABDOMEN 1 TX AREA,5000183,CDM,969,RC,SS183,HCPCS,OUTPATIENT,,,3240,1944,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6859.94,8511,
V-FORM 6 - 8 ABDOMEN 2 TX AREAS,5000184,CDM,969,RC,SS184,HCPCS,OUTPATIENT,,,6120,3672,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6860.94,8512,
V-FORM 6 - 8 FLANKS,5000185,CDM,969,RC,SS185,HCPCS,OUTPATIENT,,,2520,1512,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6861.94,8513,
V-FORM 6 - 8 BUTTOCKS,5000186,CDM,969,RC,SS186,HCPCS,OUTPATIENT,,,2880,1728,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6862.94,8514,
99070 Supplies and materials,5000187,CDM,983,RC,99070,HCPCS,OUTPATIENT,,,25,15,,,,,,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,6863.94,8515,
V-FORM 6 - 8 LEGS ANTERIOR/POSTERIOR/INNER,5000188,CDM,969,RC,SS188,HCPCS,OUTPATIENT,,,3600,2160,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6864.94,8516,
V-FORM 6 - 8 BRA/BACK FAT,5000189,CDM,969,RC,SS189,HCPCS,OUTPATIENT,,,2250,1350,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6865.94,8517,
V-FORM 6 - 8 JOWLS/SUBMENTAL,5000190,CDM,969,RC,SS190,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6866.94,8518,
"Annual Wellness Visit, Subsequent (AWV)",5000191,CDM,983,RC,G0439,HCPCS,OUTPATIENT,,,214,128.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,122.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6867.94,8519,
99310 Subsq Nursing Facility Care 45 Minutes,5000192,CDM,977,RC,99310,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6868.94,8520,
99309 Subsq Nursing Facility Care 30 Minutes,5000193,CDM,977,RC,99309,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,101.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6869.94,8521,
99308 Subsq Nursing Facility Care 15 Minutes,5000194,CDM,977,RC,99308,HCPCS,OUTPATIENT,,,133,79.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6870.94,8522,
99307 Subsq Nursing Facility Care 10 Minutes,5000195,CDM,977,RC,99307,HCPCS,OUTPATIENT,,,86,51.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6871.94,8523,
Tetanus and diphtheria toxoids (Td) 7yrs up,5000196,CDM,983,RC,90714,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.66,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6872.94,8524,
"Measles, Mumps, Rubella  Varicella Vaccine",5000197,CDM,983,RC,90715,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.52,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6873.94,8525,
"Therapeutic, Prophylactic, or Diagnostic Injection;Subcutaneous or Intramuscular",5000198,CDM,983,RC,90772,HCPCS,OUTPATIENT,,,88,52.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6874.94,8526,
"Smoking and Tobacco Cessation Counseling, Asymptomatic, 3-10 Minutes",5000199,CDM,983,RC,99406,HCPCS,OUTPATIENT,,,48,28.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,15.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,11.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6875.94,8527,
"Smoking and Tobacco Cessation Counseling, Asymptomatic, >10 Minutes",5000200,CDM,983,RC,99407,HCPCS,OUTPATIENT,,,99,59.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,28.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6876.94,8528,
UNLISTED INJECTION,5000201,CDM,983,RC,J3490,HCPCS,OUTPATIENT,,,3,1.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6877.94,8529,
99199 UNLISTED EM,5000203,CDM,983,RC,99199,HCPCS,OUTPATIENT,,,15,9,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6878.94,8530,
"Influenza virus vaccine, quadrivalent, split virus, when adm to 3 yrs and older",5000207,CDM,983,RC,90648,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,13.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6879.94,8531,
"90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule),",5000208,CDM,983,RC,90647,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,31.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6880.94,8532,
Varicella Virus Vaccine POC,5000210,CDM,983,RC,90716,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,171.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6881.94,8533,
"90633 Hepatitis A vaccine, pediatric dosage-2 dose",5000211,CDM,983,RC,90633,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6882.94,8534,
"Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for IM Use POC",5000212,CDM,983,RC,90634,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,26.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6883.94,8535,
"Hemophilus Influenza B Vaccine (Hib), PRP-OMP conj. 3-dose IM use POC",5000213,CDM,983,RC,90647,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,31.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6884.94,8536,
90649 THS Gardasil Sd Hpv Vacci,5000214,CDM,983,RC,90649,HCPCS,OUTPATIENT,,,310,186,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,182.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6885.94,8537,
(HPV 9)  Human Papilloma Vaccine,5000215,CDM,983,RC,90651,HCPCS,OUTPATIENT,,,322,193.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,288.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6886.94,8538,
Fluzone (36 months and older),5000216,CDM,983,RC,90656,HCPCS,OUTPATIENT,,,85,51,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,19.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,22.35,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6887.94,8539,
"90658 Influenza virus vaccine, trivalent, split virus 3yr+",5000217,CDM,983,RC,90658,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,18.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.85,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6888.94,8540,
90670 THS Prevnar 12 Valent,5000219,CDM,983,RC,90670,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,283.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,257.98,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6889.94,8541,
"90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use",5000220,CDM,983,RC,90680,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6890.94,8542,
"Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza",5000222,CDM,983,RC,90698,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6891.94,8543,
90700 THS Dtap < 7 Yrs Of Age,5000223,CDM,983,RC,90700,HCPCS,OUTPATIENT,,,46,27.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6892.94,8544,
MMR Measles/Mumps/Rubella Virus Vaccine POC,5000224,CDM,983,RC,90707,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6893.94,8545,
90710 THS MMRV (ProQuad) POC,5000225,CDM,983,RC,90710,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,284.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6894.94,8546,
90714 THS TETANUS-DIPHTHERIA TOXOIDS (TD),5000226,CDM,983,RC,90714,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.66,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6895.94,8547,
90715 TDAP VACCINE 7 YRS/> IM,5000227,CDM,983,RC,90715,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.52,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6896.94,8548,
TDAP VACCINE 7 YEARS OR OLDER,5000227,CDM,983,RC,90715,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.52,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6897.94,8549,
90715 THS Tdap 7Yrs  Older,5000227,CDM,983,RC,90715,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.52,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6898.94,8550,
90715 TDAP VACCINE 7 YRS/> IM,5000227,CDM,983,RC,90715,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.52,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6899.94,8551,
90716 Varicella virus vaccine,5000228,CDM,983,RC,90716,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,171.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6900.94,8552,
90723 THS DtaP-HepB-IPV POC,5000229,CDM,983,RC,90723,HCPCS,OUTPATIENT,,,160,96,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,101.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6901.94,8553,
90732 THS Pneumonia Vaccine 2Yr,5000230,CDM,636,RC,90732,HCPCS,OUTPATIENT,,,156,93.6,,,,,,other,Not separately reimbursable,200.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,200.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.83,35.15,,,fee schedule,35.15% of LA custom fee schedule,49.84,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,333.68,100,,,case rate,pays based on per visit rate,49.84,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6902.94,8554,
90734 THS Meningococcal Conjugate,5000231,CDM,983,RC,90734,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,161.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6903.94,8555,
TDAP VACCINE > 7 YEARS,5000232,CDM,983,RC,90715,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.52,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6904.94,8556,
90632 Hepatitis A Vaccine Adult,5000233,CDM,983,RC,90632,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.47,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6905.94,8557,
"90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), f",5000235,CDM,983,RC,90648,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,13.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6906.94,8558,
"90657 Influenza virus vaccine, trivalent, split virus",5000236,CDM,983,RC,90657,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,10.92,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6907.94,8559,
Flu Vaccine Live Intranasal POC,5000237,CDM,983,RC,90660,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,28.87,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6908.94,8560,
90696 THS Kinrix 0.5ML Vaccine,5000238,CDM,983,RC,90696,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,64.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6909.94,8561,
Tetanus Toxoid POC,5000239,CDM,983,RC,90702,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6910.94,8562,
IPV Inactivated Poliovirus Vaccine POC,5000240,CDM,983,RC,90713,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6911.94,8563,
"Hepatitis B Vaccine, Adult",5000242,CDM,983,RC,90746,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.37,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6912.94,8564,
90748 THS HEP B/HIB COMVAX,5000243,CDM,983,RC,90748,HCPCS,OUTPATIENT,,,9.45,5.67,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6913.94,8565,
"11055 Paring or Cutting of Benign Hyperkeratotic Lesion (eg,",5000244,CDM,983,RC,11055,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,58.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6914.94,8566,
"11055 Paring or Cutting of Benign Hyperkeratotic Lesion (eg,",5000244,CDM,983,RC,11055,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,58.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6915.94,8567,
57150 IRRIGATION VAGINA/APPL MEDICAMENT TX DISEASE,5000245,CDM,521,RC,57150,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,42.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,42.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,6916.94,8568,
MED SERV EVE/WKEND/HOLIDAY,5000246,CDM,521,RC,99051,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,40,50,,32,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,40,50,,32,percent of total billed charges,50% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,32,40,,25.6,percent of total billed charges,40% of total billed charges,6917.94,8569,
11200 REMOVAL OF SKIN TAGS,5000247,CDM,521,RC,11200,HCPCS,OUTPATIENT,,,227,136.2,,192.95,85,,154.36,Percent of total billed charges,85% of total billed charges,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,72.53,31.95,,58.024,percent of total billed charges,31.95% of total billed charges,72.53,31.95,,58.024,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,86.26,38,,69.008,percent of total billed charges,38% of total billed charges,90.8,40,,72.64,percent of total billed charges,40% of total billed charges,6918.94,8570,
Remove Skin Tag Each Add'l 10 Skin Tags Charge,5000248,CDM,521,RC,11201,HCPCS,OUTPATIENT,,,52,31.2,,44.2,85,,35.36,Percent of total billed charges,85% of total billed charges,409.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,409.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,16.61,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,16.61,31.95,,13.288,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,19.76,38,,15.808,percent of total billed charges,38% of total billed charges,20.8,40,,16.64,percent of total billed charges,40% of total billed charges,6919.94,8571,
20605 DRAIN/INJ INTERM JNT/BURSA W/O US,5000249,CDM,960,RC,20605,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6920.94,8572,
58100 BIOPSY OF UTERUS LINING,5000251,CDM,521,RC,58100,HCPCS,OUTPATIENT,,,332,199.2,,282.2,85,,225.76,Percent of total billed charges,85% of total billed charges,315.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,315.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,106.07,31.95,,84.856,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,126.16,38,,100.928,percent of total billed charges,38% of total billed charges,132.8,40,,106.24,percent of total billed charges,40% of total billed charges,6921.94,8573,
57500 BIOPSY OF CERVIX,5000252,CDM,521,RC,57500,HCPCS,OUTPATIENT,,,312,187.2,,265.2,85,,212.16,Percent of total billed charges,85% of total billed charges,1041.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1041.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,99.68,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,99.68,31.95,,79.744,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,118.56,38,,94.848,percent of total billed charges,38% of total billed charges,124.8,40,,99.84,percent of total billed charges,40% of total billed charges,6922.94,8574,
11102 Tangntl bx skin single lesion,5000253,CDM,521,RC,11102,HCPCS,OUTPATIENT,,,233,139.8,,198.05,85,,158.44,Percent of total billed charges,85% of total billed charges,742.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,742.27,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,74.44,31.95,,59.552,percent of total billed charges,31.95% of total billed charges,74.44,31.95,,59.552,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,88.54,38,,70.832,percent of total billed charges,38% of total billed charges,93.2,40,,74.56,percent of total billed charges,40% of total billed charges,6923.94,8575,
11400 EXC TR-EXT B9+MARG 0.5 CM<,5000254,CDM,521,RC,11400,HCPCS,OUTPATIENT,,,249,149.4,,211.65,85,,169.32,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.56,31.95,,63.648,percent of total billed charges,31.95% of total billed charges,79.56,31.95,,63.648,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,94.62,38,,75.696,percent of total billed charges,38% of total billed charges,99.6,40,,79.68,percent of total billed charges,40% of total billed charges,6924.94,8576,
11732 REMOVE NAIL PLATE ADD-ON,5000255,CDM,521,RC,11732,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,20.9,38,,16.72,percent of total billed charges,38% of total billed charges,22,40,,17.6,percent of total billed charges,40% of total billed charges,6925.94,8577,
20552 INJ TRIGGER POINT 1/2 MUSCL,5000256,CDM,521,RC,20552,HCPCS,OUTPATIENT,,,117,70.2,,99.45,85,,79.56,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,37.38,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,37.38,31.95,,29.904,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,44.46,38,,35.568,percent of total billed charges,38% of total billed charges,46.8,40,,37.44,percent of total billed charges,40% of total billed charges,6926.94,8578,
20600 DRAIN/INJECT SM JNT/BURSA W/O US,5000257,CDM,521,RC,20600,HCPCS,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,41.8,38,,33.44,percent of total billed charges,38% of total billed charges,44,40,,35.2,percent of total billed charges,40% of total billed charges,6927.94,8579,
G0010 ADMINISTRATION HEP B VACCINE,5000258,CDM,521,RC,G0010,HCPCS,OUTPATIENT,,,60,36,,51,85,,40.8,Percent of total billed charges,85% of total billed charges,30,50,,24,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,30,50,,24,percent of total billed charges,50% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,19.17,31.95,,15.336,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,22.8,38,,18.24,percent of total billed charges,38% of total billed charges,24,40,,19.2,percent of total billed charges,40% of total billed charges,6928.94,8580,
58300 INSERTION INTRAUTERINE DEVICE IUD,5000259,CDM,521,RC,58300,HCPCS,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,66.5,38,,53.2,percent of total billed charges,38% of total billed charges,70,40,,56,percent of total billed charges,40% of total billed charges,6929.94,8581,
58301 REMOVAL INTRAUTERINE DEVICE IUD,5000260,CDM,521,RC,58301,HCPCS,OUTPATIENT,,,140,84,,119,85,,95.2,Percent of total billed charges,85% of total billed charges,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,56,40,,44.8,percent of total billed charges,40% of total billed charges,6930.94,8582,
Cervical/Vaginal CA Screen; Pelvic/Breast Exam Charge,5000261,CDM,521,RC,19499,HCPCS,OUTPATIENT,,,152,91.2,,129.2,85,,103.36,Percent of total billed charges,85% of total billed charges,4865.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4865.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,48.56,31.95,,38.848,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,57.76,38,,46.208,percent of total billed charges,38% of total billed charges,60.8,40,,48.64,percent of total billed charges,40% of total billed charges,6931.94,8583,
DRUG TEST PRSMV CHEM ANLYZR,5000262,CDM,300,RC,80307,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,223.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,223.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.35,110,,,fee schedule,110% of LA custom fee schedule,62.14,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.8,38,,48.64,percent of total billed charges,38% of total billed charges,62.14,100,,,Fee Schedule,100% of LA custom fee schedule,6932.94,8584,
80307 DRUG TEST PRSMV CHEM ANLYZR,5000262,CDM,300,RC,80307,HCPCS,OUTPATIENT,,,160,96,,136,85,,108.8,Percent of total billed charges,85% of total billed charges,223.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,223.2,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.35,110,,,fee schedule,110% of LA custom fee schedule,62.14,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,60.8,38,,48.64,percent of total billed charges,38% of total billed charges,62.14,100,,,Fee Schedule,100% of LA custom fee schedule,6933.94,8585,
Chron care mgmt srvc 20 min,5000263,CDM,521,RC,G0511,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,49,50,,39.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,49,50,,39.2,percent of total billed charges,50% of total billed charges,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,37.24,38,,29.792,percent of total billed charges,38% of total billed charges,39.2,40,,31.36,percent of total billed charges,40% of total billed charges,6934.94,8586,
CMPLX CHRON CARE W/O PT VSIT,5000264,CDM,510,RC,99487,HCPCS,OUTPATIENT,,,159,95.4,,135.15,85,,108.12,Percent of total billed charges,85% of total billed charges,266.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,266.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,50.8,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,50.8,31.95,,40.64,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,60.42,38,,48.336,percent of total billed charges,38% of total billed charges,63.6,40,,50.88,percent of total billed charges,40% of total billed charges,6935.94,8587,
COMP ASSES CARE PLAN CCM SVC,5000265,CDM,510,RC,G0506,HCPCS,OUTPATIENT,,,139,83.4,,118.15,85,,94.52,Percent of total billed charges,85% of total billed charges,69.5,50,,55.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,69.5,50,,55.6,percent of total billed charges,50% of total billed charges,44.41,31.95,,35.528,percent of total billed charges,31.95% of total billed charges,44.41,31.95,,35.528,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,52.82,38,,42.256,percent of total billed charges,38% of total billed charges,55.6,40,,44.48,percent of total billed charges,40% of total billed charges,6936.94,8588,
PHYS EST  DOC NEED PWR MOBIL DEVC,5000266,CDM,510,RC,G0372,HCPCS,OUTPATIENT,,,36,21.6,,30.6,85,,24.48,Percent of total billed charges,85% of total billed charges,18,50,,14.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,18,50,,14.4,percent of total billed charges,50% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,13.68,38,,10.944,percent of total billed charges,38% of total billed charges,14.4,40,,11.52,percent of total billed charges,40% of total billed charges,6937.94,8589,
G0402 INIT PREV PE LTD DUR 1ST 12 MOS MCR,5000267,CDM,521,RC,G0402,HCPCS,OUTPATIENT,,,259,155.4,,220.15,85,,176.12,Percent of total billed charges,85% of total billed charges,233.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,233.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,82.75,31.95,,66.2,percent of total billed charges,31.95% of total billed charges,82.75,31.95,,66.2,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,98.42,38,,78.736,percent of total billed charges,38% of total billed charges,103.6,40,,82.88,percent of total billed charges,40% of total billed charges,6938.94,8590,
10160 PUNCTURE DRAINAGE OF LESION,5000268,CDM,510,RC,10160,HCPCS,OUTPATIENT,,,276,165.6,,234.6,85,,187.68,Percent of total billed charges,85% of total billed charges,138,50,,110.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,138,50,,110.4,percent of total billed charges,50% of total billed charges,88.18,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,88.18,31.95,,70.544,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,104.88,38,,83.904,percent of total billed charges,38% of total billed charges,110.4,40,,88.32,percent of total billed charges,40% of total billed charges,6939.94,8591,
64450 N BLOCK OTHER PERIPHERAL,5000269,CDM,510,RC,64450,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,92,40,,73.6,percent of total billed charges,40% of total billed charges,6940.94,8592,
20520 REMOVAL OF FOREIGN BODY,5000270,CDM,521,RC,20520,HCPCS,OUTPATIENT,,,304,182.4,,258.4,85,,206.72,Percent of total billed charges,85% of total billed charges,1038.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1038.45,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,97.13,31.95,,77.704,percent of total billed charges,31.95% of total billed charges,97.13,31.95,,77.704,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,115.52,38,,92.416,percent of total billed charges,38% of total billed charges,121.6,40,,97.28,percent of total billed charges,40% of total billed charges,6941.94,8593,
"J1380 Injection, estradiol valerate, up to 10 mg",5000271,CDM,636,RC,J1380,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,15.95,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,15.95,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.03,35.15,,5.624,percent of total billed charges,35.15% of total billed charges,15.52,31.95,,12.416,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6942.94,8594,
RHo(D) immune globulin Injection 300 mcg,5000272,CDM,636,RC,J2790,HCPCS,OUTPATIENT,,,412,247.2,,350.2,85,,280.16,Percent of total billed charges,85% of total billed charges,116.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,116.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,144.82,35.15,,,fee schedule,35.15% of LA custom fee schedule,131.63,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.63,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6943.94,8595,
Adrenalin epinephrine inject,5000274,CDM,636,RC,J0171,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,1.17,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.17,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.03,35.15,,,fee schedule,35.15% of LA custom fee schedule,6.39,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.39,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6944.94,8596,
DEBRIDEMENT OPEN WOUND 20 SQ CM/<,5000275,CDM,510,RC,97597,HCPCS,OUTPATIENT,,,340,204,,289,85,,231.2,Percent of total billed charges,85% of total billed charges,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,170.87,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,129.2,38,,103.36,percent of total billed charges,38% of total billed charges,136,40,,108.8,percent of total billed charges,40% of total billed charges,6945.94,8597,
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS,5000276,CDM,510,RC,97602,HCPCS,OUTPATIENT,,,340,204,,289,85,,231.2,Percent of total billed charges,85% of total billed charges,399.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,399.06,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,108.63,31.95,,86.904,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,129.2,38,,103.36,percent of total billed charges,38% of total billed charges,136,40,,108.8,percent of total billed charges,40% of total billed charges,6946.94,8598,
Cytopath c/v interpret,5000277,CDM,521,RC,88141,HCPCS,OUTPATIENT,,,94,56.4,,79.9,85,,63.92,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,30.03,31.95,,24.024,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,35.72,38,,28.576,percent of total billed charges,38% of total billed charges,37.6,40,,30.08,percent of total billed charges,40% of total billed charges,6947.94,8599,
J7620 ALbuterol 2.5mg/Ipratronium 1.25mg,5000278,CDM,250,RC,J7620,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.23,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,6948.94,8600,
J7626 Pulmicort RT (BUDESONIDE 0.5mg),5000279,CDM,250,RC,J7626,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,1.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.73,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,6949.94,8601,
J7644 Atrovent (ipratropium) 0.5mg RT ipratropium 0.02% Inh,5000280,CDM,250,RC,J7644,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,6950.94,8602,
Priv Ins - Flu Vaccine 6 through 35 months-0.25 mL(single-do,5000284,CDM,983,RC,90685,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6951.94,8603,
DESTRUCT PREMALG LESION 1ST,5000285,CDM,510,RC,17000,HCPCS,OUTPATIENT,,,188,112.8,,159.8,85,,127.84,Percent of total billed charges,85% of total billed charges,148.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,148.28,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,60.07,31.95,,48.056,percent of total billed charges,31.95% of total billed charges,60.07,31.95,,48.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,71.44,38,,57.152,percent of total billed charges,38% of total billed charges,75.2,40,,60.16,percent of total billed charges,40% of total billed charges,6952.94,8604,
Insert Foley Cath Prof,5000286,CDM,977,RC,51702,HCPCS,OUTPATIENT,,,195,117,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6953.94,8605,
"11103 Tangetial biopsy, each additional lesion",5000290,CDM,983,RC,11103,HCPCS,OUTPATIENT,,,126,75.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,56.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6954.94,8606,
11104 Punch bx of skin; single lesion,5000292,CDM,983,RC,11104,HCPCS,OUTPATIENT,,,293,175.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6955.94,8607,
11105 Punch bx skin ea sep/addl,5000295,CDM,983,RC,11105,HCPCS,OUTPATIENT,,,145,87,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,64.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6956.94,8608,
11106 Incal bx skn single les,5000298,CDM,983,RC,11106,HCPCS,OUTPATIENT,,,355,213,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,158.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6957.94,8609,
11107 Incal bx skn ea sep/addl,5000300,CDM,983,RC,11107,HCPCS,OUTPATIENT,,,171,102.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,28.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6958.94,8610,
Cont Gluc Mntr PT Prov Eqp,5000335,CDM,920,RC,95249,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,322.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,322.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.91,35.15,,,fee schedule,35.15% of LA custom fee schedule,33.55,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,39.9,38,,31.92,percent of total billed charges,38% of total billed charges,33.55,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6959.94,8611,
Cont Gluc Mntr Phys Prov Eqp,5000336,CDM,920,RC,95250,HCPCS,OUTPATIENT,,,270,162,,229.5,85,,183.6,Percent of total billed charges,85% of total billed charges,322.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,322.99,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,94.91,35.15,,,fee schedule,35.15% of LA custom fee schedule,86.27,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,102.6,38,,82.08,percent of total billed charges,38% of total billed charges,86.27,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6960.94,8612,
Cont Gluc Mntr Analysis IR,5000337,CDM,920,RC,95251,HCPCS,OUTPATIENT,,,72,43.2,,61.2,85,,48.96,Percent of total billed charges,85% of total billed charges,36,50,,28.8,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,36,50,,28.8,percent of total billed charges,50% of total billed charges,25.31,35.15,,,fee schedule,35.15% of LA custom fee schedule,23,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,27.36,38,,21.888,percent of total billed charges,38% of total billed charges,23,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,6961.94,8613,
99441 PHYS/QHP TELEPHONE EVAL 5-10 MIN,5000343,CDM,978,RC,99441,HCPCS,OUTPATIENT,,,35,21,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6962.94,8614,
99442 PHYS/QHP TELEPHONE EVAL 11-20 MIN,5000344,CDM,978,RC,99442,HCPCS,OUTPATIENT,,,55,33,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,27.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6963.94,8615,
99443 PHYS/QHP TELEPHONE EVAL 21-30 MIN,5000345,CDM,978,RC,99443,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6964.94,8616,
G2012 PHYS/QHP BRIEF COMMUNICATION 5-10 MIN,5000346,CDM,978,RC,G2012,HCPCS,OUTPATIENT,,,35,21,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,12.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6965.94,8617,
G0071 RHC/FQHC COMM SVCS 5 MIN BCE,5000347,CDM,978,RC,G0071,HCPCS,OUTPATIENT,,,35,21,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,16.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6966.94,8618,
G2025 RHC/FQHC DIS SITE TELE SVCS,5000348,CDM,521,RC,G2025,HCPCS,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,43.7,38,,34.96,percent of total billed charges,38% of total billed charges,46,40,,36.8,percent of total billed charges,40% of total billed charges,6967.94,8619,
ADMN SARSCOV2 VACC 1 DOSE,5000375,CDM,771,RC,90480,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,25,50,,20,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,25,50,,20,percent of total billed charges,50% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,35,100,,,case rate,pays based on per visit rate,20,40,,16,percent of total billed charges,40% of total billed charges,6968.94,8620,
HRT Female Pre Pellet LC,5000400,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6969.94,8621,
BHRT Male New Patient Initial Labs Pre Pellet,5000401,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6970.94,8622,
HRT Male Pre Pellet LC,5000401,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,210,126,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6971.94,8623,
HRT Female Post Pellet w/o TPO LC,5000402,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6972.94,8624,
HRT Male Post Pellet w/o TPO LC,5000403,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6973.94,8625,
HRT Female Post Pellet Thyroid LC,5000404,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6974.94,8626,
HRT Male Post Pellet Thyroid LC,5000405,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,160,96,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6975.94,8627,
BHRT Female Post Pellet RX Thyroid w/o TPO,5000406,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6976.94,8628,
BHRT Male Post Pellet RX Thyroid w/o TPO,5000407,CDM,969,RC,BHRT,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6977.94,8629,
ADK 10,5000408,CDM,969,RC,SS803,HCPCS,OUTPATIENT,,,28,16.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6978.94,8630,
ADK 5,5000409,CDM,969,RC,SS804,HCPCS,OUTPATIENT,,,28,16.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6979.94,8631,
Arterosil HP,5000410,CDM,969,RC,SS805,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6980.94,8632,
Curcumin SF,5000411,CDM,969,RC,SS806,HCPCS,OUTPATIENT,,,21,12.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6981.94,8633,
DIM SGS,5000412,CDM,969,RC,SS807,HCPCS,OUTPATIENT,,,33,19.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6982.94,8634,
Iodine+,5000413,CDM,969,RC,SS808,HCPCS,OUTPATIENT,,,33,19.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6983.94,8635,
Methyl Factors,5000414,CDM,969,RC,SS809,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6984.94,8636,
Omega 3+CoQ10,5000415,CDM,969,RC,SS810,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6985.94,8637,
Omega 30 Plus,5000416,CDM,969,RC,SS811,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6986.94,8638,
Thorne,5000417,CDM,969,RC,SS812,HCPCS,OUTPATIENT,,,14,8.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6987.94,8639,
Multi-Strain Probiotic 20B,5000418,CDM,969,RC,SS813,HCPCS,OUTPATIENT,,,21,12.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6988.94,8640,
Hair Rescue Activate,5000419,CDM,969,RC,SS814,HCPCS,OUTPATIENT,,,44,26.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6989.94,8641,
Hair Rescue Repair,5000420,CDM,969,RC,SS815,HCPCS,OUTPATIENT,,,44,26.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6990.94,8642,
Luminate,5000421,CDM,969,RC,SS816,HCPCS,OUTPATIENT,,,69,41.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6991.94,8643,
Urox+,5000422,CDM,969,RC,SS817,HCPCS,OUTPATIENT,,,29,17.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6992.94,8644,
vH Balance,5000423,CDM,969,RC,SS822,HCPCS,OUTPATIENT,,,33,19.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6993.94,8645,
Best Night Sleep,5000424,CDM,969,RC,SS819,HCPCS,OUTPATIENT,,,28,16.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6994.94,8646,
Serene,5000425,CDM,969,RC,SS820,HCPCS,OUTPATIENT,,,35,21,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6995.94,8647,
Vascanox HP,5000426,CDM,969,RC,SS821,HCPCS,OUTPATIENT,,,38,22.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6996.94,8648,
BioTe NutraPack,5000427,CDM,969,RC,SS823,HCPCS,OUTPATIENT,,,38,22.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6997.94,8649,
BioTe NutraPack Plus,5000428,CDM,969,RC,SS824,HCPCS,OUTPATIENT,,,50,30,,,,,,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,6998.94,8650,
Juvederm Ultra 1mL,5000440,CDM,969,RC,SS400,HCPCS,OUTPATIENT,,,675,405,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6999.94,8651,
Juvederm Ultra .55mL,5000441,CDM,969,RC,SS401,HCPCS,OUTPATIENT,,,475,285,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7000.94,8652,
ZO Stimulator Peel,5000456,CDM,969,RC,SS441,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7001.94,8653,
ZO 3-Step Peel,5000457,CDM,969,RC,SS442,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7002.94,8654,
ZO Dual Action Scrub,5000458,CDM,969,RC,SS458,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7003.94,8655,
ZO Dual Action Scrub Travel,5000459,CDM,969,RC,SS459,HCPCS,OUTPATIENT,,,50,30,,,,,,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,7004.94,8656,
ZO Gentle Cleanser,5000460,CDM,969,RC,SS460,HCPCS,OUTPATIENT,,,49,29.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7005.94,8657,
ZO Exfoliating Polish,5000461,CDM,969,RC,SS461,HCPCS,OUTPATIENT,,,68,40.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7006.94,8658,
ZO Complexion Renewal Pads,5000462,CDM,969,RC,SS462,HCPCS,OUTPATIENT,,,59,35.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7007.94,8659,
ZO Pigment Control Cr?me 4% HQ,5000463,CDM,969,RC,SS463,HCPCS,OUTPATIENT,,,77,46.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7008.94,8660,
ZO Pigment Control + Blending Cr?me 4% HQ,5000464,CDM,969,RC,SS464,HCPCS,OUTPATIENT,,,77,46.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7009.94,8661,
ZO Daily Power Defense,5000465,CDM,969,RC,SS465,HCPCS,OUTPATIENT,,,173,103.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7010.94,8662,
ZO Illuminating AOX Serum,5000466,CDM,969,RC,SS479,HCPCS,OUTPATIENT,,,178,106.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7011.94,8663,
ZO Growth Factor Serum,5000467,CDM,969,RC,SS467,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7012.94,8664,
ZO Firming Serum,5000468,CDM,969,RC,SS468,HCPCS,OUTPATIENT,,,248,148.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7013.94,8665,
ZO Wrinkle + Texture Repair,5000469,CDM,969,RC,SS469,HCPCS,OUTPATIENT,,,159,95.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7014.94,8666,
ZO Enzymatic Peel,5000470,CDM,969,RC,SS470,HCPCS,OUTPATIENT,,,85,51,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7015.94,8667,
ZO Brightalive Skin Brightener,5000471,CDM,969,RC,SS471,HCPCS,OUTPATIENT,,,145,87,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7016.94,8668,
ZO Retinol Skin Brightener 0.25%,5000472,CDM,969,RC,SS472,HCPCS,OUTPATIENT,,,110,66,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7017.94,8669,
ZO Sunscreen + Primer SPF 30,5000473,CDM,969,RC,SS473,HCPCS,OUTPATIENT,,,67,40.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7018.94,8670,
ZO Smart Tone SPF 50,5000474,CDM,969,RC,SS480,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7019.94,8671,
ZO Gel Sunscreen SPF 50,5000475,CDM,969,RC,SS475,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7020.94,8672,
ZO Sheer Fluid SPF 50,5000476,CDM,969,RC,SS476,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7021.94,8673,
ZO Hydrating Cr?me,5000477,CDM,969,RC,SS477,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7022.94,8674,
ZO Growth Factor Eye Serum,5000478,CDM,969,RC,SS478,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7023.94,8675,
ZO Gentle Cleanser Travel,5000479,CDM,969,RC,SS009,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7024.94,8676,
ZO Exfoliating Polish Travel,5000480,CDM,969,RC,SS010,HCPCS,OUTPATIENT,,,21,12.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7025.94,8677,
ZO Complexion Renewal Pads Travel,5000481,CDM,969,RC,SS481,HCPCS,OUTPATIENT,,,30,18,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7026.94,8678,
ZO Daily Power Defense Travel,5000482,CDM,969,RC,SS012,HCPCS,OUTPATIENT,,,108,64.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7027.94,8679,
ZO Brightalive Skin Brightener Travel,5000483,CDM,969,RC,SS483,HCPCS,OUTPATIENT,,,94,56.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7028.94,8680,
ZO Sunscreen + Primer SPF 30 Travel,5000484,CDM,969,RC,SS484,HCPCS,OUTPATIENT,,,37,22.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7029.94,8681,
ZO Smart Tone SPF 50 Travel,5000485,CDM,969,RC,SS485,HCPCS,OUTPATIENT,,,35,21,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7030.94,8682,
ZO Hydrating Cr?me Travel,5000486,CDM,969,RC,SS486,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7031.94,8683,
ZO Exfoliating Cleanser Normal/Oily Skin,5000487,CDM,969,RC,SS487,HCPCS,OUTPATIENT,,,49,29.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7032.94,8684,
ZO Exfoliating Cleanser Normal/Oily Skin Travel,5000488,CDM,969,RC,SS488,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7033.94,8685,
ZO Hydrating Cleanser Normal/Dry Skin,5000489,CDM,969,RC,SS489,HCPCS,OUTPATIENT,,,49,29.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7034.94,8686,
ZO Hydrating Cleanser Normal/Dry Skin Travel,5000490,CDM,969,RC,SS013,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7035.94,8687,
ZO Calming Toner pH Balancer,5000491,CDM,969,RC,SS491,HCPCS,OUTPATIENT,,,46,27.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7036.94,8688,
ZO Calming Toner pH Balancer Travel,5000492,CDM,969,RC,SS492,HCPCS,OUTPATIENT,,,15,9,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7037.94,8689,
ZO 10% Vitamin C Self-Activating,5000493,CDM,969,RC,SS493,HCPCS,OUTPATIENT,,,108,64.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7038.94,8690,
ZO 10% Vitamin C Self-Activating Travel,5000494,CDM,969,RC,SS494,HCPCS,OUTPATIENT,,,50,30,,,,,,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,7039.94,8691,
ZO Complexion Clearing Masque,5000495,CDM,969,RC,SS495,HCPCS,OUTPATIENT,,,48,28.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7040.94,8692,
ZO Rozatrol,5000496,CDM,969,RC,SS496,HCPCS,OUTPATIENT,,,93,55.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7041.94,8693,
ZO Rozatrol Travel,5000497,CDM,969,RC,SS497,HCPCS,OUTPATIENT,,,41,24.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7042.94,8694,
ZO Sunscreen + Powder SPF 45 Medium,5000498,CDM,969,RC,SS498,HCPCS,OUTPATIENT,,,65,39,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7043.94,8695,
ZO Anti-Aging Program,5000499,CDM,969,RC,SS499,HCPCS,OUTPATIENT,,,240,144,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7044.94,8696,
90620 Meningococcal recombinant protein and outer membrane v,5000500,CDM,250,RC,90620,HCPCS,OUTPATIENT,,,280,168,,238,85,,190.4,Percent of total billed charges,85% of total billed charges,328.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,328.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,98.42,35.15,,,fee schedule,35.15% of LA custom fee schedule,89.46,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,106.4,38,,85.12,percent of total billed charges,38% of total billed charges,89.46,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7045.94,8697,
BEXSERA(MENINGOCOCCAL B VACC 4-COMP),5000500,CDM,636,RC,90620,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,328.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,328.89,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,,fee schedule,35.15% of LA custom fee schedule,3.02,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.02,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7046.94,8698,
VFC 90677 THS Prevnar 20 Valent,5000508,CDM,521,RC,90677,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,433.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,433.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.78,40,,3.024,percent of total billed charges,40% of total billed charges,7047.94,8699,
90677 PREVNAR 20,5000508,CDM,636,RC,90677,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,433.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,433.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,721.65,100,,,case rate,pays based on per visit rate,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,7048.94,8700,
Pneumococcal 20-valent Vaccine,5000508,CDM,636,RC,90677,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,433.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,433.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.45,35.15,,84.36,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,721.65,100,,,case rate,pays based on per visit rate,95.85,31.95,,76.68,percent of total billed charges,31.95% of total billed charges,7049.94,8701,
Bupivacaine 0.5% Inj Sol,5000521,CDM,636,RC,J0665,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,0.03,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.03,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.03,35.15,,5.624,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,7050.94,8702,
J7323 sodium hyaluronate,5000522,CDM,636,RC,J7323,HCPCS,OUTPATIENT,,,635,381,,539.75,85,,431.8,Percent of total billed charges,85% of total billed charges,185.02,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,185.02,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,223.2,35.15,,178.56,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,323.68,100,,,case rate,pays based on per visit rate,202.88,31.95,,162.304,percent of total billed charges,31.95% of total billed charges,7051.94,8703,
J7324 hyaluronan,5000523,CDM,636,RC,J7324,HCPCS,OUTPATIENT,,,945,567,,803.25,85,,642.6,Percent of total billed charges,85% of total billed charges,204.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,332.17,35.15,,265.736,percent of total billed charges,35.15% of total billed charges,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,336.15,100,,,case rate,pays based on per visit rate,301.93,31.95,,241.544,percent of total billed charges,31.95% of total billed charges,7052.94,8704,
SoluMedrol (methylprednisolone),5000526,CDM,636,RC,J2919,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,0.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.41,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.03,35.15,,5.624,percent of total billed charges,35.15% of total billed charges,5.75,31.95,,4.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,7053.94,8705,
Tuberculin purified protein derivative Sol,5000527,CDM,636,RC,86580,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,29.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.81,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.03,35.15,,5.624,percent of total billed charges,35.15% of total billed charges,111.83,31.95,,89.464,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,7054.94,8706,
Rotovirus (Rotarix) Oral Vaccine,5000528,CDM,636,RC,90681,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,209.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,209.6,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,2.656,percent of total billed charges,35.15% of total billed charges,1.6,31.95,,1.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,7055.94,8707,
90381 VFC Nirsevimab-alip (Beyfortus-RSV) 1.0 mL Injection F,5000546,CDM,250,RC,90381,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,4.73,50,,3.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.73,50,,3.784,percent of total billed charges,50% of total billed charges,3.32,35.15,,2.656,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,7056.94,8708,
90381 Nirsevimab-alip (Beyfortus-RSV) 1.0 mL Injection FMC,5000546,CDM,250,RC,90381,HCPCS,OUTPATIENT,,,495,297,,420.75,85,,336.6,Percent of total billed charges,85% of total billed charges,247.5,50,,198,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,247.5,50,,198,percent of total billed charges,50% of total billed charges,173.99,35.15,,139.192,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,188.1,38,,150.48,percent of total billed charges,38% of total billed charges,158.15,31.95,,126.52,percent of total billed charges,31.95% of total billed charges,7057.94,8709,
90380 VFC Nirsevimab-alip (Beyfortus-RSV) 0.5 mL Injection F,5000547,CDM,250,RC,90380,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,4.73,50,,3.784,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,4.73,50,,3.784,percent of total billed charges,50% of total billed charges,3.32,35.15,,2.656,percent of total billed charges,35.15% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,7058.94,8710,
90380 Nirsevimab-alip (Beyfortus-RSV) 0.5 mL Injection FMC,5000547,CDM,250,RC,90380,HCPCS,OUTPATIENT,,,495,297,,420.75,85,,336.6,Percent of total billed charges,85% of total billed charges,247.5,50,,198,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,247.5,50,,198,percent of total billed charges,50% of total billed charges,173.99,35.15,,139.192,percent of total billed charges,35.15% of total billed charges,1.28,31.95,,1.024,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,188.1,38,,150.48,percent of total billed charges,38% of total billed charges,158.15,31.95,,126.52,percent of total billed charges,31.95% of total billed charges,7059.94,8711,
Fluzone Trivalent 6mo-17yr,5000550,CDM,636,RC,90656,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,27.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,27.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,12.3,35.15,,,fee schedule,35.15% of LA custom fee schedule,11.18,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,32.2,100,,,case rate,pays based on per visit rate,11.18,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7060.94,8712,
FLublok Vaccine 18yr+,5000551,CDM,636,RC,90673,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,55.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,29.88,35.15,,23.904,percent of total billed charges,35.15% of total billed charges,23.15,31.95,,18.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,7061.94,8713,
J7609 Albuterol RT FMC,5000552,CDM,250,RC,J7609,HCPCS,OUTPATIENT,,,12,7.2,,10.2,85,,8.16,Percent of total billed charges,85% of total billed charges,0.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.75,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.22,35.15,,3.376,percent of total billed charges,35.15% of total billed charges,23.15,31.95,,18.52,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,4.56,38,,3.648,percent of total billed charges,38% of total billed charges,3.83,31.95,,3.064,percent of total billed charges,31.95% of total billed charges,7062.94,8714,
90697 Vaxelis,5000567,CDM,636,RC,90697,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,2.656,percent of total billed charges,35.15% of total billed charges,24,31.95,,19.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,7063.94,8715,
VFC Vaxelis vaccine,5000567,CDM,636,RC,90697,HCPCS,OUTPATIENT,,,9,5.4,,7.65,85,,6.12,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.16,35.15,,2.528,percent of total billed charges,35.15% of total billed charges,3.23,31.95,,2.584,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2.88,31.95,,2.304,percent of total billed charges,31.95% of total billed charges,7064.94,8716,
Fluzone Quadrivalent 6mo-17yr 2022-2023,5000570,CDM,636,RC,90688,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,28.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.55,35.15,,,fee schedule,35.15% of LA custom fee schedule,9.59,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.2,100,,,case rate,pays based on per visit rate,9.59,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7065.94,8717,
Fluzone Quadrivalent 6mo-17yr 2022-2023,5000570,CDM,636,RC,90688,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,28.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,28.52,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.55,35.15,,,fee schedule,35.15% of LA custom fee schedule,9.59,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,51.2,100,,,case rate,pays based on per visit rate,9.59,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7066.94,8718,
"Meningococcal Groups A, C, Y, W Conjugate Vaccine, Solution",5000571,CDM,636,RC,90619,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,242.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,242.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,70.3,35.15,,56.24,percent of total billed charges,35.15% of total billed charges,3.25,31.95,,2.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,7067.94,8719,
"VFC Meningococcal Groups A, C, Y, W Conjugate Vaccine, Sol",5000571,CDM,636,RC,90619,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,242.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,242.9,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,2.656,percent of total billed charges,35.15% of total billed charges,3.25,31.95,,2.6,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,7068.94,8720,
Pneumococcal 15-valent Vaccine,5000572,CDM,636,RC,90671,HCPCS,OUTPATIENT,,,320,192,,272,85,,217.6,Percent of total billed charges,85% of total billed charges,369.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,369.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,112.48,35.15,,89.984,percent of total billed charges,35.15% of total billed charges,1.15,31.95,,0.92,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,615.5,100,,,case rate,pays based on per visit rate,102.24,31.95,,81.792,percent of total billed charges,31.95% of total billed charges,7069.94,8721,
VFC Pneumococcal 15-valent Vaccine,5000572,CDM,636,RC,90671,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,369.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,369.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,2.656,percent of total billed charges,35.15% of total billed charges,1.2,31.95,,0.96,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,615.5,100,,,case rate,pays based on per visit rate,3.02,31.95,,2.416,percent of total billed charges,31.95% of total billed charges,7070.94,8722,
INJ CARPAL TUNNEL THERAPEUTIC,5000706,CDM,521,RC,20526,HCPCS,OUTPATIENT,,,140,84,,119,85,,95.2,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,56,40,,44.8,percent of total billed charges,40% of total billed charges,7071.94,8723,
INJ SINGLE TENDON SHEATH/LIG,5000720,CDM,521,RC,20550,HCPCS,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,38.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,38.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,45.6,38,,36.48,percent of total billed charges,38% of total billed charges,48,40,,38.4,percent of total billed charges,40% of total billed charges,7072.94,8724,
INJ SINGLE TENDON ORIGIN/INSERT,5000721,CDM,521,RC,20551,HCPCS,OUTPATIENT,,,120,72,,102,85,,81.6,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,38.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,38.34,31.95,,30.672,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,45.6,38,,36.48,percent of total billed charges,38% of total billed charges,48,40,,38.4,percent of total billed charges,40% of total billed charges,7073.94,8725,
INJ TRIGGER POINT 3/> MUSCLES,5000722,CDM,521,RC,20553,HCPCS,OUTPATIENT,,,130,78,,110.5,85,,88.4,Percent of total billed charges,85% of total billed charges,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,567.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,41.54,31.95,,33.232,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,49.4,38,,39.52,percent of total billed charges,38% of total billed charges,52,40,,41.6,percent of total billed charges,40% of total billed charges,7074.94,8726,
CAST APP LONG ARM,5000740,CDM,521,RC,29065,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,76,38,,60.8,percent of total billed charges,38% of total billed charges,80,40,,64,percent of total billed charges,40% of total billed charges,7075.94,8727,
CAST APP SHORT ARM,5000745,CDM,521,RC,29075,HCPCS,OUTPATIENT,,,180,108,,153,85,,122.4,Percent of total billed charges,85% of total billed charges,90,50,,72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90,50,,72,percent of total billed charges,50% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,68.4,38,,54.72,percent of total billed charges,38% of total billed charges,72,40,,57.6,percent of total billed charges,40% of total billed charges,7076.94,8728,
CASTAPP GAUNTLETHAND/LOWFOREARM,5000750,CDM,521,RC,29085,HCPCS,OUTPATIENT,,,195,117,,165.75,85,,132.6,Percent of total billed charges,85% of total billed charges,97.5,50,,78,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,97.5,50,,78,percent of total billed charges,50% of total billed charges,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,62.3,31.95,,49.84,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,74.1,38,,59.28,percent of total billed charges,38% of total billed charges,78,40,,62.4,percent of total billed charges,40% of total billed charges,7077.94,8729,
SPLINTAPPLONGARM,5000755,CDM,521,RC,29105,HCPCS,OUTPATIENT,,,127,76.2,,107.95,85,,86.36,Percent of total billed charges,85% of total billed charges,501.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,501.61,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,40.58,31.95,,32.464,percent of total billed charges,31.95% of total billed charges,40.58,31.95,,32.464,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,48.26,38,,38.608,percent of total billed charges,38% of total billed charges,50.8,40,,40.64,percent of total billed charges,40% of total billed charges,7078.94,8730,
STRAPPING ELBOW/WRIST,5000760,CDM,521,RC,29260,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.5,50,,22,percent of total billed charges,50% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,20.9,38,,16.72,percent of total billed charges,38% of total billed charges,22,40,,17.6,percent of total billed charges,40% of total billed charges,7079.94,8731,
CAST APP LONG LEG,5000765,CDM,521,RC,29345,HCPCS,OUTPATIENT,,,245,147,,208.25,85,,166.6,Percent of total billed charges,85% of total billed charges,122.5,50,,98,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,122.5,50,,98,percent of total billed charges,50% of total billed charges,78.28,31.95,,62.624,percent of total billed charges,31.95% of total billed charges,78.28,31.95,,62.624,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,93.1,38,,74.48,percent of total billed charges,38% of total billed charges,98,40,,78.4,percent of total billed charges,40% of total billed charges,7080.94,8732,
CAST APP SHORT LEG,5000770,CDM,521,RC,29405,HCPCS,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,85,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,64.6,38,,51.68,percent of total billed charges,38% of total billed charges,68,40,,54.4,percent of total billed charges,40% of total billed charges,7081.94,8733,
SPLINT APP LONG LEG,5000775,CDM,975,RC,29505,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,126.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7082.94,8734,
STRAPPING KNEE,5000780,CDM,521,RC,29530,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.5,50,,22,percent of total billed charges,50% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,20.9,38,,16.72,percent of total billed charges,38% of total billed charges,22,40,,17.6,percent of total billed charges,40% of total billed charges,7083.94,8735,
STRAPPING ANKLE  and/OR FOOT,5000785,CDM,521,RC,29540,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,27.5,50,,22,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,27.5,50,,22,percent of total billed charges,50% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,20.9,38,,16.72,percent of total billed charges,38% of total billed charges,22,40,,17.6,percent of total billed charges,40% of total billed charges,7084.94,8736,
RMVL/BIVALVE FULL ARM/LEG CAST,5000790,CDM,975,RC,29705,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7085.94,8737,
NERVE BLOCK INJ PLANTAR DIGIT,5000800,CDM,521,RC,64455,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,691.14,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,691.14,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,7086.94,8738,
99417 OP Prolonged Service Addl 15 Minutes,5000817,CDM,983,RC,99417,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,28.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7087.94,8739,
VSL FUNC SCRNG AUTO SEMI-AUTO BI QUAN DETERM,5000872,CDM,521,RC,99172,HCPCS,OUTPATIENT,,,48,28.8,,40.8,85,,32.64,Percent of total billed charges,85% of total billed charges,24,50,,19.2,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,24,50,,19.2,percent of total billed charges,50% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,15.34,31.95,,12.272,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,18.24,38,,14.592,percent of total billed charges,38% of total billed charges,19.2,40,,15.36,percent of total billed charges,40% of total billed charges,7088.94,8740,
ZO Daily Skincare Program,5001000,CDM,969,RC,SS014,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7089.94,8741,
ZO Complexion Clearing Kit,5001001,CDM,969,RC,SS015,HCPCS,OUTPATIENT,,,150,90,,,,,,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,7090.94,8742,
ZO Firming Serum Accelerated,5001002,CDM,969,RC,SS016,HCPCS,OUTPATIENT,,,45,27,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7091.94,8743,
ZO Rozatrol Accelerated,5001003,CDM,969,RC,SS017,HCPCS,OUTPATIENT,,,45,27,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7092.94,8744,
ZO BrightAlive Accelerated,5001004,CDM,969,RC,SS018,HCPCS,OUTPATIENT,,,45,27,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7093.94,8745,
ZO Gentle Cleanser Backbar,5001005,CDM,969,RC,SS443,HCPCS,OUTPATIENT,,,50,30,,,,,,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,7094.94,8746,
ZO Balancing Cleansing Emulsion,5001006,CDM,969,RC,SS444,HCPCS,OUTPATIENT,,,52,31.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7095.94,8747,
ZO Oil Control Pads,5001007,CDM,969,RC,SS445,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7096.94,8748,
ZO Daily Power Defense Backbar,5001008,CDM,969,RC,SS446,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7097.94,8749,
ZO Exfoliation Accelerator,5001009,CDM,969,RC,SS447,HCPCS,OUTPATIENT,,,82,49.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7098.94,8750,
ZO Exfoliation Accelerator Travel,5001010,CDM,969,RC,SS448,HCPCS,OUTPATIENT,,,52,31.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7099.94,8751,
ZO Instant Pore Refiner,5001011,CDM,969,RC,SS449,HCPCS,OUTPATIENT,,,62,37.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7100.94,8752,
ZO Radical Night Repair 1% Retinol,5001012,CDM,969,RC,SS450,HCPCS,OUTPATIENT,,,185,111,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7101.94,8753,
ZO Complex A+,5001013,CDM,969,RC,SS451,HCPCS,OUTPATIENT,,,95,57,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7102.94,8754,
ZO Acne Control,5001014,CDM,969,RC,SS452,HCPCS,OUTPATIENT,,,39,23.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7103.94,8755,
ZO Complexion Clarifying Serum,5001015,CDM,969,RC,SS453,HCPCS,OUTPATIENT,,,110,66,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7104.94,8756,
ZO Renewal Cr?me,5001016,CDM,969,RC,SS454,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7105.94,8757,
ZO Recovery Cr?me,5001017,CDM,969,RC,SS455,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7106.94,8758,
ZO Astringent Solution Powder,5001018,CDM,969,RC,SS456,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7107.94,8759,
ZO Soothing Ointment,5001019,CDM,969,RC,SS457,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7108.94,8760,
ZO Intense Eye Cr?me,5001020,CDM,969,RC,SS500,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7109.94,8761,
ZO Eye Brightening Cr?me,5001021,CDM,969,RC,SS501,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7110.94,8762,
ZO Body Emulsion Cr?me,5001022,CDM,969,RC,SS502,HCPCS,OUTPATIENT,,,98,58.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7111.94,8763,
ZO Body Smoothing Cr?me,5001023,CDM,969,RC,SS503,HCPCS,OUTPATIENT,,,98,58.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7112.94,8764,
ZO Daily Sheer Broad Spectrum SPF 50,5001024,CDM,969,RC,SS504,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7113.94,8765,
ZO Broad Spectrum SPF 50,5001025,CDM,969,RC,SS505,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7114.94,8766,
ZO Skin Brightening Kit,5001026,CDM,969,RC,SS506,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7115.94,8767,
ZO Skin Normalizing Kit,5001027,CDM,969,RC,SS507,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7116.94,8768,
ZO Retinol + Acne Complex,5001028,CDM,969,RC,SS508,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7117.94,8769,
HYDRINITY Age Renewal Kit,5001050,CDM,969,RC,SS019,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7118.94,8770,
HYDRINITY Eye Renew Complex 15mL,5001051,CDM,969,RC,SS020,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7119.94,8771,
HYDRINITY Eye Renew Complex 5mL,5001052,CDM,969,RC,SS021,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7120.94,8772,
HYDRINITY Hyacin Active 90mL,5001053,CDM,969,RC,SS022,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7121.94,8773,
HYDRINITY Renewing HA Serum 30mL,5001054,CDM,969,RC,SS023,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7122.94,8774,
HYDRINITY Renewing HA Serum 5mL,5001055,CDM,969,RC,SS024,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7123.94,8775,
HYDRINITY Restorative HA Serum 120mL,5001056,CDM,969,RC,SS025,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7124.94,8776,
HYDRINITY Restorative HA Serum 30mL,5001057,CDM,969,RC,SS026,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7125.94,8777,
HYDRINITY Restorative HA Serum 5mL,5001058,CDM,969,RC,SS027,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7126.94,8778,
HYDRINITY Restorative Kit,5001059,CDM,969,RC,SS028,HCPCS,OUTPATIENT,,,160,96,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7127.94,8779,
HYDRINITY Vivid Brightening Serum 30mL,5001060,CDM,969,RC,SS030,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7128.94,8780,
HYDRINITY Vivid Brightening Serum 5mL,5001061,CDM,969,RC,SS031,HCPCS,OUTPATIENT,,,20,12,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7129.94,8781,
V-IPL ACNE CLEARANCE FULL FACE,5001064,CDM,969,RC,SS164,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7130.94,8782,
V-IPL ACNE CLEARANCE UPPER  and LOWER FACE,5001065,CDM,969,RC,SS165,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7131.94,8783,
V-IPL ACNE CLEARANCE SUBMENTAL  and NECK,5001066,CDM,969,RC,SS166,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7132.94,8784,
V-IPL ACNE CLEARANCE CHEST,5001067,CDM,969,RC,SS167,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7133.94,8785,
V-IPL ACNE CLEARANCE BACK,5001068,CDM,969,RC,SS168,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7134.94,8786,
V-IPL ACNE CLEARANCE ARMS,5001069,CDM,969,RC,SS169,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7135.94,8787,
V-FORM 1 FACE LOWER FACE,5001070,CDM,969,RC,SS170,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7136.94,8788,
V-FORM 1 FACE LOWER FACE,5001070,CDM,969,RC,SS170,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7137.94,8789,
V-FORM 1 FACE LOWER FACE/JOWL,5001072,CDM,969,RC,SS172,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,450,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7138.94,8790,
V-FORM 1 UPPER TORSO UPPER BACK,5001073,CDM,969,RC,SS173,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7139.94,8791,
V-FORM 1 UPPER TORSO FULL BACK,5001074,CDM,969,RC,SS174,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7140.94,8792,
V-FORM 1 LOWER TORSO ABDOMEN,5001075,CDM,983,RC,SS175,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7141.94,8793,
V-FORM 1 LOWER TORSO FLANK,5001076,CDM,983,RC,SS176,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7142.94,8794,
V-FORM 1 LOWER TORSO ABDOMEN/FLANK,5001077,CDM,983,RC,SS177,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7143.94,8795,
V-FORM 1 LOWER TORSO LOWER BACK/LOVE HANDLES,5001078,CDM,983,RC,SS178,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7144.94,8796,
V-FORM 1 LOWER TORSO BUTTOCKS,5001079,CDM,983,RC,SS179,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7145.94,8797,
V-FORM 1 LOWER TORSO ABDOMEN/BUTTOCKS,5001080,CDM,983,RC,SS180,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7146.94,8798,
V-FORM 1 LIMBS ARMS,5001081,CDM,969,RC,SS181,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7147.94,8799,
V-FORM 1 LIMBS LEGS BACK THIGHS,5001082,CDM,983,RC,SS082,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7148.94,8800,
V-FORM 1 LIMBS LEGS FRONT THIGHS,5001083,CDM,983,RC,SS059,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7149.94,8801,
V-FORM 1 LIMBS FULL LEGS W/BUTTOCKS,5001084,CDM,983,RC,SS060,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7150.94,8802,
V-FR 3 STRETCH MARKS/SCARS,5001085,CDM,969,RC,SS061,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2160,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7151.94,8803,
V-FR 3 ACNE SCAR CORRECTION,5001086,CDM,969,RC,SS062,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2160,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7152.94,8804,
V-FR 3 WRINKLES/LAXITY HALF FACE,5001087,CDM,983,RC,SS087,HCPCS,OUTPATIENT,,,630,378,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,630,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7153.94,8805,
V-FR 3 WRINKLES/LAXITY FULL FACE,5001088,CDM,983,RC,SS088,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7154.94,8806,
V-FR 3 HYPERPIGMENTATION,5001089,CDM,969,RC,SS089,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7155.94,8807,
V-FR 3 LABIA,5001090,CDM,969,RC,SS090,HCPCS,OUTPATIENT,,,1890,1134,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1890,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7156.94,8808,
V-FR 3 NECK,5001091,CDM,969,RC,SS091,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7157.94,8809,
V-FR 3 DECOLLETE,5001092,CDM,969,RC,SS092,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7158.94,8810,
V-FR 3 KNEES/HANDS/ELBOWS,5001093,CDM,969,RC,SS093,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7159.94,8811,
V-FR 4 STRETCH MARKS/SCARS,5001094,CDM,969,RC,SS094,HCPCS,OUTPATIENT,,,2720,1632,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2720,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7160.94,8812,
V-FR 4 ACNE SCAR CORRECTION,5001095,CDM,969,RC,SS095,HCPCS,OUTPATIENT,,,2720,1632,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2720,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7161.94,8813,
V-FR 4 WRINKLES/LAXITY HALF FACE,5001096,CDM,969,RC,SS096,HCPCS,OUTPATIENT,,,1700,1020,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7162.94,8814,
V-FR 4 WRINKLES/LAXITY FULL FACE,5001097,CDM,969,RC,SS097,HCPCS,OUTPATIENT,,,2380,1428,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2380,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7163.94,8815,
V-FR 4 HYPERPIGMENTATION,5001098,CDM,969,RC,SS098,HCPCS,OUTPATIENT,,,2040,1224,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2040,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7164.94,8816,
V-FR 4 LABIA,5001099,CDM,969,RC,SS099,HCPCS,OUTPATIENT,,,2380,1428,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2380,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7165.94,8817,
V-FR 4 NECK,5001100,CDM,969,RC,SS100,HCPCS,OUTPATIENT,,,2040,1224,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2040,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7166.94,8818,
V-FR 4 DECOLLETE,5001101,CDM,969,RC,SS101,HCPCS,OUTPATIENT,,,2040,1224,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2040,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7167.94,8819,
V-FR 5 STRETCH MARKS/SCARS,5001103,CDM,969,RC,SS103,HCPCS,OUTPATIENT,,,3400,2040,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7168.94,8820,
V-FR 5 ACNE SCAR CORRECTION,5001104,CDM,969,RC,SS104,HCPCS,OUTPATIENT,,,3400,2040,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7169.94,8821,
V-FR 5 WRINKLES/LAXITY HALF FACE,5001105,CDM,969,RC,SS105,HCPCS,OUTPATIENT,,,2125,1275,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2125,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7170.94,8822,
V-FR 5 WRINKLES/LAXITY FULL FACE,5001106,CDM,969,RC,SS106,HCPCS,OUTPATIENT,,,2975,1785,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2975,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7171.94,8823,
V-FR 5 HYPERPIGMENTATION,5001107,CDM,969,RC,SS107,HCPCS,OUTPATIENT,,,2550,1530,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2550,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7172.94,8824,
V-FR 5 LABIA,5001108,CDM,969,RC,SS108,HCPCS,OUTPATIENT,,,2975,1785,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2975,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7173.94,8825,
V-FR 5 NECK,5001109,CDM,969,RC,SS109,HCPCS,OUTPATIENT,,,2975,1785,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2975,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7174.94,8826,
V-FR 5 DECOLLETE,5001110,CDM,969,RC,SS110,HCPCS,OUTPATIENT,,,2975,1785,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2975,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7175.94,8827,
V-FR 5 KNEES/HANDS/ELBOWS,5001111,CDM,969,RC,SS111,HCPCS,OUTPATIENT,,,2975,1785,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2975,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7176.94,8828,
V-FR 6 STRETCH MARKS/SCARS,5001112,CDM,969,RC,SS112,HCPCS,OUTPATIENT,,,3840,2304,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3840,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7177.94,8829,
V-FR 6 ACNE SCAR CORRECTION,5001113,CDM,969,RC,SS113,HCPCS,OUTPATIENT,,,3840,2304,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3840,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7178.94,8830,
V-FR 6 WRINKLES/LAXITY HALF FACE,5001114,CDM,969,RC,SS114,HCPCS,OUTPATIENT,,,2400,1440,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7179.94,8831,
V-FR 6 WRINKLES/LAXITY FULL FACE,5001115,CDM,969,RC,SS115,HCPCS,OUTPATIENT,,,3360,2016,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3360,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7180.94,8832,
V-FR 6 HYPERPIGMENTATION,5001116,CDM,969,RC,SS116,HCPCS,OUTPATIENT,,,2800,1680,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7181.94,8833,
V-FR 6 LABIA,5001117,CDM,969,RC,SS117,HCPCS,OUTPATIENT,,,3360,2016,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3360,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7182.94,8834,
V-FR 6 NECK,5001118,CDM,969,RC,SS118,HCPCS,OUTPATIENT,,,2800,1680,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7183.94,8835,
V-FR 6 DECOLLETE,5001119,CDM,969,RC,SS119,HCPCS,OUTPATIENT,,,2800,1680,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7184.94,8836,
V-FR 6 KNEES/HANDS/ELBOWS,5001120,CDM,969,RC,SS120,HCPCS,OUTPATIENT,,,2800,1680,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7185.94,8837,
V-FR 1 SKIN CORRECT/PERFECT STRETCH MARKS/SCARS,5001121,CDM,969,RC,SS121,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7186.94,8838,
V-FR 1 SKIN CORRECTION/PERFECTION ACNE SCAR CORRECTION,5001122,CDM,969,RC,SS122,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7187.94,8839,
V-FR 1 SKIN CORRECTION/PERFECTION WRINKLES/LAXITY/TEXTURE HA,5001123,CDM,969,RC,SS123,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7188.94,8840,
V-FR 1 SKIN CORRECTION/PERFECTION WRINKLES/LAXITY/TEXTURE FU,5001124,CDM,969,RC,SS124,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7189.94,8841,
V-FR 1 SKIN CORRECTION/PERFECTION HYPERPIGMENTATION,5001125,CDM,969,RC,SS125,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7190.94,8842,
V-FR 1 SKIN CORRECTION/PERFECTION LABIA,5001126,CDM,969,RC,SS126,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7191.94,8843,
V-FR 1 SKIN CORRECTION/PERFECTION NECK,5001127,CDM,969,RC,SS127,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7192.94,8844,
V-FR 1 SKIN CORRECTION/PERFECTION DECOLLETE,5001128,CDM,969,RC,SS128,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7193.94,8845,
V-FR 1 SKIN PERFECTION/CORRECTION KNEES/HANDS/ELBOWS,5001129,CDM,969,RC,SS129,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7194.94,8846,
DERMAFUSE 1/ADD ON INTENSIVE HYDRATION,5001130,CDM,969,RC,SS130,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7195.94,8847,
DERMAFUSE 1/ADD ON COLLAGEN BOOSTER,5001131,CDM,969,RC,SS131,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7196.94,8848,
DERMAFUSE 1/ADD ON SMOOTH,5001132,CDM,969,RC,SS132,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7197.94,8849,
DERMAFUSE 1/ADD ON BRIGHT,5001133,CDM,969,RC,SS133,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7198.94,8850,
DERMAFUSE INTENSIVE HYDRATION 6 - 10,5001134,CDM,969,RC,SS134,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7199.94,8851,
DERMAFUSE COLLAGEN BOOSTER 6 - 10,5001135,CDM,969,RC,SS135,HCPCS,OUTPATIENT,,,1750,1050,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7200.94,8852,
PREIME AQUAB,5001136,CDM,983,RC,SS136,HCPCS,OUTPATIENT,,,149,89.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,149,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7201.94,8853,
PREIME AQUAB+,5001137,CDM,969,RC,SS137,HCPCS,OUTPATIENT,,,209,125.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,209,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7202.94,8854,
PREIME AQUAB LIFT,5001138,CDM,983,RC,SS138,HCPCS,OUTPATIENT,,,269,161.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,269,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7203.94,8855,
PREIME AQUABLIFT+,5001139,CDM,969,RC,SS054,HCPCS,OUTPATIENT,,,289,173.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,289,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7204.94,8856,
PREIME AQUAB BRIGHT,5001140,CDM,983,RC,SS055,HCPCS,OUTPATIENT,,,299,179.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,299,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7205.94,8857,
PREIME AQUAB BRIGHT+,5001141,CDM,969,RC,SS056,HCPCS,OUTPATIENT,,,329,197.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,329,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7206.94,8858,
PREIME AQUAB FRESH,5001142,CDM,983,RC,SS142,HCPCS,OUTPATIENT,,,299,179.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,299,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7207.94,8859,
PREIME AQUAB FRESH+,5001143,CDM,969,RC,SS143,HCPCS,OUTPATIENT,,,329,197.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,329,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7208.94,8860,
PREIME AQUAB ULTIMATE,5001144,CDM,983,RC,SS144,HCPCS,OUTPATIENT,,,399,239.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,399,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7209.94,8861,
ELYSION FACE UPPER LIP,5001145,CDM,983,RC,SS145,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7210.94,8862,
ELYSION FACE CHIN,5001146,CDM,983,RC,SS146,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7211.94,8863,
ELYSION FACE CHEEKS,5001147,CDM,983,RC,SS147,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7212.94,8864,
ELYSION FACE LIP/CHIN,5001148,CDM,983,RC,SS148,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7213.94,8865,
ELYSION NECK UNISEX,5001149,CDM,969,RC,SS149,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7214.94,8866,
ELYSION UP TORSO DECOLLETE,5001150,CDM,969,RC,SS150,HCPCS,OUTPATIENT,,,375,225,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,375,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7215.94,8867,
ELYSION UP TORSO AREOLA/NIPPLE AREA,5001151,CDM,969,RC,SS151,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7216.94,8868,
ELYSION UP TORSO SHOULDERS,5001152,CDM,969,RC,SS152,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7217.94,8869,
ELYSION UP TORSO UP BACK,5001153,CDM,969,RC,SS153,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7218.94,8870,
ELYSION UP TORSO LOWER BACK,5001154,CDM,969,RC,SS154,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7219.94,8871,
ELYSION UP TORSO FULL BACK,5001155,CDM,969,RC,SS155,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7220.94,8872,
ELYSION UP TORSO COMPLETE TORSO,5001156,CDM,969,RC,SS156,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7221.94,8873,
ELYSION LOWER TORSO BIKINI LINE ONLY,5001157,CDM,983,RC,SS157,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7222.94,8874,
ELYSION LOWER TORSO BIKINI ENTIRE AREA,5001158,CDM,983,RC,SS158,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7223.94,8875,
ELYSION LOWER TORSO BUTTOCKS,5001159,CDM,983,RC,SS159,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7224.94,8876,
ELYSION LOWER TORSO AXILLAE/UNDERARMS,5001160,CDM,983,RC,SS160,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7225.94,8877,
ELYSION LOW TORSO UPPER/LOWER ARMS,5001161,CDM,969,RC,SS161,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7226.94,8878,
ELYSION LOW TORSO FULL ARMS,5001162,CDM,969,RC,SS162,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7227.94,8879,
ELYSION LOW TORSO HANDS/FINGERS,5001163,CDM,969,RC,SS163,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7228.94,8880,
ELYSION LOWER BODY HALF LEGS,5001164,CDM,983,RC,SS057,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7229.94,8881,
ELYSION LOWER BODY FULL LEGS,5001165,CDM,969,RC,SS058,HCPCS,OUTPATIENT,,,475,285,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,475,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7230.94,8882,
ENERJET 1-3 KINETIC LIFT 1 ML SYRINGE,5001166,CDM,983,RC,SS566,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7231.94,8883,
ENERJET KINETIC LIFT ADD 1 ML SYRINGE,5001167,CDM,983,RC,SS567,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7232.94,8884,
ENERJET 1-3 DERMAL THICKENING 1 ML,5001168,CDM,969,RC,SS568,HCPCS,OUTPATIENT,,,1500,900,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7233.94,8885,
ENERJET DERMAL THICKENING ADD 1 ML,5001169,CDM,969,RC,SS569,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7234.94,8886,
ENERJET 1-3 FINE LINES/WRINKLES 1 ML,5001170,CDM,969,RC,SS570,HCPCS,OUTPATIENT,,,1500,900,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7235.94,8887,
ENERJET FINE LINES/WRINKLES ADD 1 ML,5001171,CDM,969,RC,SS571,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7236.94,8888,
ENERJET 1-3 ATROPHIC/ACNE SCARS 1 ML,5001172,CDM,969,RC,SS572,HCPCS,OUTPATIENT,,,1750,1050,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7237.94,8889,
ENERJET ATROPHIC/ACNE SCARS ADD 1 ML,5001173,CDM,969,RC,SS573,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7238.94,8890,
ENERJET 1 - 3 STRETCH MARKS 1 ML SYRINGE,5001174,CDM,969,RC,SS574,HCPCS,OUTPATIENT,,,1500,900,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7239.94,8891,
ENERJET STRETCH MARKS ADD 1 ML SYRINGE,5001175,CDM,969,RC,SS575,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7240.94,8892,
ENERJET 5-10 HYPERTROPHIC/KELOID SCARS 1 ML,5001176,CDM,969,RC,SS576,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7241.94,8893,
ENERJET HYPERTROPHIC/KELOID SCARS ADD 1 ML,5001177,CDM,969,RC,SS577,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7242.94,8894,
V-ST 4 - 6  EYES,5001178,CDM,969,RC,SS578,HCPCS,OUTPATIENT,,,1080,648,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1080,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7243.94,8895,
V-ST 4 - 6  FOREHEAD,5001179,CDM,969,RC,SS579,HCPCS,OUTPATIENT,,,1080,648,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1080,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7244.94,8896,
V-ST 4 - 6  NASAL LABIAL FOLD,5001180,CDM,969,RC,SS580,HCPCS,OUTPATIENT,,,810,486,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,810,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7245.94,8897,
V-ST 4 - 6  LOWER FACE,5001181,CDM,969,RC,SS581,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2160,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7246.94,8898,
V-ST 4 - 6  FULL FACE,5001182,CDM,969,RC,SS582,HCPCS,OUTPATIENT,,,2430,1458,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2430,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7247.94,8899,
V-ST 4 - 6  SUBMENTAL/NECK,5001183,CDM,969,RC,SS583,HCPCS,OUTPATIENT,,,2430,1458,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2430,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7248.94,8900,
V-ST 4 - 6  SUBMENTAL/NECK,5001183,CDM,969,RC,SS583,HCPCS,OUTPATIENT,,,2430,1458,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2430,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7249.94,8901,
V-ST 4 - 6  HANDS,5001185,CDM,969,RC,SS585,HCPCS,OUTPATIENT,,,1080,648,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1080,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7250.94,8902,
V-ST 4 - 6  DECOLLETE,5001186,CDM,969,RC,SS586,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7251.94,8903,
V-ST 4 - 6  STRETCH MARKS BODY,5001187,CDM,969,RC,SS587,HCPCS,OUTPATIENT,,,1080,648,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1080,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7252.94,8904,
V-ST 4 - 6  SCARS,5001188,CDM,969,RC,SS588,HCPCS,OUTPATIENT,,,1080,648,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1080,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7253.94,8905,
V-IPL 4-6 PIGMENT FRECKLES 40 MIN,5001189,CDM,969,RC,SS044,HCPCS,OUTPATIENT,,,1485,891,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1485,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7254.94,8906,
V-IPL 4-6 PIGMENT SOLAR LENTIGO 40 MIN,5001190,CDM,969,RC,SS048,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7255.94,8907,
V-IPL 4-6 PIGMENT KERATOSIS 30 MIN,5001191,CDM,969,RC,SS191,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7256.94,8908,
V-IPL 4-6 PIGMENT CAFE-AU-LAIT 40 MIN,5001192,CDM,969,RC,SS192,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7257.94,8909,
V-IPL 4-6 PIGMENT MELASMA 40 MIN,5001193,CDM,969,RC,SS193,HCPCS,OUTPATIENT,,,1890,1134,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1890,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7258.94,8910,
V-IPL 4-6 PIGMENT HEMOSIDERIN 50 MIN,5001194,CDM,969,RC,SS194,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7259.94,8911,
V-IPL 4-6 PIGMENT BECKER NEVUS 50 MIN,5001195,CDM,969,RC,SS195,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2160,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7260.94,8912,
V-IPL 4-6 ACNE CLEARANCE FACE 40 MIN,5001196,CDM,969,RC,SS196,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7261.94,8913,
V-IPL 4-6 ACNE CLEARANCE NECK 30 MIN,5001197,CDM,969,RC,SS197,HCPCS,OUTPATIENT,,,1080,648,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1080,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7262.94,8914,
V-IPL 4-6 ACNE CLEARANCE FACE  and NECK 60 MIN,5001198,CDM,969,RC,SS198,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2160,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7263.94,8915,
V-IPL 4-6 ACNE CLEARANCE CHEST 40 MIN,5001199,CDM,969,RC,SS199,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7264.94,8916,
V-IPL 4-6 ACNE CLEARANCE BACK 50 MIN,5001200,CDM,969,RC,SS200,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7265.94,8917,
V-IPL 4-6 ACNE CLEARANCE ARMS 40 MIN,5001201,CDM,969,RC,SS201,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7266.94,8918,
V-IPL 4-6 VASC LESIONS FACIAL TELANGIECTASIA 40 MIN,5001202,CDM,969,RC,SS202,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7267.94,8919,
V-IPL 4-6 VASC LESIONS ERYTHEMA OF ROSACEA 30 MIN,5001203,CDM,969,RC,SS203,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7268.94,8920,
V-IPL 4-6 VASC LESIONS POIKILODERMA 40 MIN,5001204,CDM,969,RC,SS204,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7269.94,8921,
V-IPL 4-6 VASC LESIONS PORT WINE STAIN 50 MIN,5001205,CDM,969,RC,SS205,HCPCS,OUTPATIENT,,,2160,1296,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2160,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7270.94,8922,
V-IPL HR 1 FACE UPPER LIP,5001206,CDM,969,RC,SS206,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7271.94,8923,
V-IPL HR 1 FACE  CHIN,5001207,CDM,969,RC,SS207,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7272.94,8924,
V-IPL HR 1 FACE  CHEEKS,5001208,CDM,969,RC,SS208,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7273.94,8925,
V-IPL HR 1 FACE  NECK WOMAN/MAN,5001209,CDM,969,RC,SS209,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7274.94,8926,
V-IPL HR 1 FACE  LIP AND CHIN,5001210,CDM,969,RC,SS210,HCPCS,OUTPATIENT,,,195,117,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,195,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7275.94,8927,
V-IPL HR 1 UPPER TORSO DECOLLETE,5001211,CDM,969,RC,SS211,HCPCS,OUTPATIENT,,,375,225,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,375,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7276.94,8928,
V-IPL HR 1 UPPER TORSO AREOLA NIPPLE AREA,5001212,CDM,969,RC,SS212,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7277.94,8929,
V-IPL HR 1 UPPER TORSO SHOULDERS,5001213,CDM,969,RC,SS213,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7278.94,8930,
V-IPL HR 1 UPPER TORSO UPPER BACK,5001214,CDM,969,RC,SS214,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7279.94,8931,
V-IPL HR 1 UPPER TORSO LOWER BACK,5001215,CDM,969,RC,SS215,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7280.94,8932,
V-IPL HR 1 UP TORSO FULL BACK,5001216,CDM,969,RC,SS216,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7281.94,8933,
V-IPL HR 1 UP TORSO COMPLETE TORSO,5001217,CDM,969,RC,SS217,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7282.94,8934,
V-IPL HR 1 LOWER TORSO BIKINI LINE ONLY,5001218,CDM,969,RC,SS218,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7283.94,8935,
V-IPL HR 1 LOW TORSO ENTIRE BIKINI,5001219,CDM,969,RC,SS219,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7284.94,8936,
V-IPL HR 1 LOW TORSO BUTTOCKS,5001220,CDM,969,RC,SS220,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7285.94,8937,
V-IPL HR 1 ARMS  and HANDS AXILLAE/UNDERARM,5001221,CDM,969,RC,SS221,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7286.94,8938,
V-IPL HR 1 ARMS  and HANDS UP/LOW ARMS,5001222,CDM,969,RC,SS222,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7287.94,8939,
V-IPL HR 1 ARMS  and HANDS FULL ARMS,5001223,CDM,969,RC,SS223,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7288.94,8940,
V-ND YAG 1 VASCULAR 30 MIN,5001223,CDM,969,RC,SS276,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7289.94,8941,
V-IPL HR 1 ARMS  and HANDS HANDS  and FINGERS,5001224,CDM,969,RC,SS224,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7290.94,8942,
V-IPL HR 1 LOWER BODY HALF LEGS,5001225,CDM,969,RC,SS225,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7291.94,8943,
V-IPL HR 1 LOWER BODY FULL LEGS,5001226,CDM,969,RC,SS226,HCPCS,OUTPATIENT,,,475,285,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,475,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7292.94,8944,
V-IPL HR 6 - 8 FACE,5001227,CDM,969,RC,SS227,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1620,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7293.94,8945,
V-IPL HR 6 - 8 UPPER LIP,5001228,CDM,969,RC,SS228,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7294.94,8946,
V-IPL HR 6 - 8 CHIN,5001229,CDM,969,RC,SS229,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7295.94,8947,
V-IPL HR 6 - 8 CHEEKS,5001230,CDM,969,RC,SS230,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7296.94,8948,
V-IPL HR 6 - 8 NECK WOMAN/MAN,5001231,CDM,969,RC,SS231,HCPCS,OUTPATIENT,,,1260,756,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1260,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7297.94,8949,
V-IPL HR 6 - 8 LIP  and CHIN COMBO,5001232,CDM,969,RC,SS232,HCPCS,OUTPATIENT,,,1755,1053,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1755,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7298.94,8950,
V-IPL HR 6 - 8 DECOLLETE,5001233,CDM,969,RC,SS233,HCPCS,OUTPATIENT,,,3375,2025,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3375,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7299.94,8951,
V-IPL HR 6 - 8 AREOLA,5001234,CDM,969,RC,SS234,HCPCS,OUTPATIENT,,,1575,945,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1575,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7300.94,8952,
V-IPL HR 6 - 8 SHOULDERS,5001235,CDM,969,RC,SS235,HCPCS,OUTPATIENT,,,3150,1890,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7301.94,8953,
V-IPL HR 6 - 8 UPPER BACK,5001236,CDM,969,RC,SS236,HCPCS,OUTPATIENT,,,2700,1620,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7302.94,8954,
V-IPL HR 6 - 8 LOWER BACK,5001237,CDM,969,RC,SS237,HCPCS,OUTPATIENT,,,2700,1620,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7303.94,8955,
V-IPL HR 6 - 8 FULL BACK,5001238,CDM,969,RC,SS238,HCPCS,OUTPATIENT,,,3600,2160,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7304.94,8956,
V-IPL HR 6 - 8 COMPLETE UPPER BODY/TORSO,5001239,CDM,969,RC,SS239,HCPCS,OUTPATIENT,,,4500,2700,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,4500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7305.94,8957,
V-IPL HR 6 - 8 BIKINI,5001240,CDM,969,RC,SS240,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7306.94,8958,
V-IPL HR 6 - 8 BRAZILIAN,5001241,CDM,969,RC,SS241,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7307.94,8959,
V-IPL HR 6 - 8 BUTTOCKS,5001242,CDM,969,RC,SS242,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7308.94,8960,
V-IPL HR 6 - 8 UNDERARMS,5001243,CDM,969,RC,SS243,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7309.94,8961,
V-IPL HR 6 - 8 UPPER/LOWER ARMS,5001244,CDM,969,RC,SS244,HCPCS,OUTPATIENT,,,1575,945,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1575,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7310.94,8962,
V-IPL HR 6 - 8 FULL ARMS,5001245,CDM,969,RC,SS245,HCPCS,OUTPATIENT,,,2250,1350,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7311.94,8963,
V-IPL HR 6 - 8 HANDS/FINGERS,5001246,CDM,969,RC,SS246,HCPCS,OUTPATIENT,,,1575,945,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1575,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7312.94,8964,
V-IPL HR 6 - 8 HALF LEGS,5001247,CDM,969,RC,SS247,HCPCS,OUTPATIENT,,,2700,1620,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7313.94,8965,
V-IPL HR 6 - 8 FULL LEGS,5001248,CDM,969,RC,SS248,HCPCS,OUTPATIENT,,,4275,2565,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,4275,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7314.94,8966,
V-ND YAG 6-10 FACE/NECK UPPER LIP,5001249,CDM,969,RC,SS249,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7315.94,8967,
V-ND YAG 6-10 FACE/NECK CHIN,5001250,CDM,969,RC,SS250,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7316.94,8968,
V-ND YAG 6-10 FACE/NECK CHEEKS,5001251,CDM,969,RC,SS251,HCPCS,OUTPATIENT,,,1350,810,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7317.94,8969,
V-ND YAG 6-10 FACE/NECK NECK UNISEX,5001252,CDM,969,RC,SS252,HCPCS,OUTPATIENT,,,1575,945,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1575,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7318.94,8970,
V-ND YAG 6-10 FACE/NECK LIP/CHIN,5001253,CDM,969,RC,SS253,HCPCS,OUTPATIENT,,,1575,945,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1575,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7319.94,8971,
V-ND YAG 6-10 UP BODY UNDERARMS,5001254,CDM,969,RC,SS254,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7320.94,8972,
V-ND YAG 6-10 UP BODY UPPER/LOWER ARMS,5001255,CDM,969,RC,SS255,HCPCS,OUTPATIENT,,,2250,1350,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7321.94,8973,
V-ND YAG 6-10 UP BODY FULL ARMS,5001256,CDM,969,RC,SS256,HCPCS,OUTPATIENT,,,3375,2025,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3375,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7322.94,8974,
V-ND YAG 6-10 UP BODY HANDS  and FINGERS,5001257,CDM,969,RC,SS257,HCPCS,OUTPATIENT,,,2925,1755,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2925,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7323.94,8975,
V-ND YAG 6-10 UP BODY DECOLLETE,5001258,CDM,969,RC,SS258,HCPCS,OUTPATIENT,,,3150,1890,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7324.94,8976,
V-ND YAG 6-10 UP BODY AREOLA,5001259,CDM,969,RC,SS259,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7325.94,8977,
V-ND YAG 6-10 UP BODY SHOULDERS,5001260,CDM,969,RC,SS260,HCPCS,OUTPATIENT,,,3150,1890,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7326.94,8978,
V-ND YAG 6-10 UP BODY UPPER BACK,5001261,CDM,969,RC,SS261,HCPCS,OUTPATIENT,,,3150,1890,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7327.94,8979,
V-ND YAG 6-10 UP BODY LOWER BACK,5001262,CDM,969,RC,SS262,HCPCS,OUTPATIENT,,,3150,1890,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7328.94,8980,
V-ND YAG 6-10 UP BODY FULL BACK,5001263,CDM,969,RC,SS263,HCPCS,OUTPATIENT,,,5400,3240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,5400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7329.94,8981,
V-ND YAG 6-10 UP BODY COMPELTE UPPER BACK,5001264,CDM,969,RC,SS264,HCPCS,OUTPATIENT,,,5400,3240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,5400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7330.94,8982,
V-ND YAG 6-10 LOWER BODY BIKINI,5001265,CDM,969,RC,SS265,HCPCS,OUTPATIENT,,,2475,1485,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2475,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7331.94,8983,
V-ND YAG 6-10 LOWER BODY BRAZILIAN,5001266,CDM,969,RC,SS266,HCPCS,OUTPATIENT,,,2925,1755,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2925,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7332.94,8984,
V-ND YAG 6-10 LOWER BODY BUTTOCKS,5001267,CDM,969,RC,SS267,HCPCS,OUTPATIENT,,,2475,1485,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2475,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7333.94,8985,
V-ND YAG 6-10 LOWER BODY HALF LEGS,5001268,CDM,969,RC,SS268,HCPCS,OUTPATIENT,,,3600,2160,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7334.94,8986,
V-ND YAG 6-10 LOWER BODY FULL LEGS,5001269,CDM,969,RC,SS269,HCPCS,OUTPATIENT,,,4500,2700,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,4500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7335.94,8987,
V-ND YAG 1 SKIN REJUV FACE,5001270,CDM,969,RC,SS270,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7336.94,8988,
V-ND YAG 1 SKIN REJUV NECK,5001271,CDM,969,RC,SS271,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7337.94,8989,
V-ND YAG 1 SKIN REJUV DECOLLETE,5001272,CDM,969,RC,SS272,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7338.94,8990,
V-ND YAG 1 SKIN REJUV HANDS,5001273,CDM,969,RC,SS273,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7339.94,8991,
V-ND YAG 1 SKIN REJUV FACE/NECK,5001274,CDM,969,RC,SS274,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7340.94,8992,
V-ND YAG 1 SKIN REJUV NECK/DECOLLETE,5001275,CDM,969,RC,SS275,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7341.94,8993,
V-ND YAG 1 VASCULAR 60 MIN,5001277,CDM,969,RC,SS277,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7342.94,8994,
V-ND YAG 1 VASCUALR 90 MIN,5001278,CDM,969,RC,SS278,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7343.94,8995,
V-ND YAG 1 FACE UPPER LIP,5001279,CDM,969,RC,SS279,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7344.94,8996,
V-ND YAG 1 FACE CHIN,5001280,CDM,969,RC,SS280,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7345.94,8997,
V-ND YAG 1 FACE CHEEKS,5001281,CDM,969,RC,SS281,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7346.94,8998,
V-ND YAG 1 FACE NECK UNISEX,5001282,CDM,969,RC,SS282,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7347.94,8999,
V-ND YAG 1 FACE LIP/CHIN,5001283,CDM,969,RC,SS283,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7348.94,9000,
V-ND YAG 1 UPPER TORSO DECOLLETE,5001284,CDM,969,RC,SS284,HCPCS,OUTPATIENT,,,375,225,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,375,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7349.94,9001,
V-ND YAG 1 UPPER TORSO AREOLA/NIPPLE,5001285,CDM,969,RC,SS285,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7350.94,9002,
V-ND YAG 1 UPPER TORSO SHOULDERS,5001286,CDM,969,RC,SS286,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7351.94,9003,
V-ND YAG 1 UPPER TORSO UPPER BACK,5001287,CDM,969,RC,SS287,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7352.94,9004,
V-ND YAG 1 UPPER TORSO LOWER BACK,5001288,CDM,969,RC,SS288,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7353.94,9005,
V-ND YAG 1 UPPER TORSO FULL BACK,5001289,CDM,969,RC,SS289,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7354.94,9006,
V-ND YAG 1 UPPER TORSO COMPLETE TORSO,5001290,CDM,969,RC,SS290,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7355.94,9007,
V-ND YAG 1 LOWER TORSO BIKINI LINE,5001291,CDM,969,RC,SS291,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7356.94,9008,
V-ND YAG 1 LOWER TORSO ENTIRE BIKINI,5001292,CDM,969,RC,SS292,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7357.94,9009,
V-ND YAG 1 LOWER TORSO BUTTOCKS,5001293,CDM,969,RC,SS293,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7358.94,9010,
V-ND YAG 1 ARM/HND/FNGR AXILLAE/UNDERARMS,5001294,CDM,969,RC,SS294,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7359.94,9011,
V-ND YAG 1 ARM/HND/FNGR UPPER/LOWER ARMS,5001295,CDM,969,RC,SS295,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7360.94,9012,
V-ND YAG 1 ARM/HND/FNGR FULL ARMS,5001296,CDM,969,RC,SS296,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7361.94,9013,
V-ND YAG 1 ARM/HND/FNGR HANDS/FINGERS,5001297,CDM,969,RC,SS297,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,175,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7362.94,9014,
V-ND YAG 1 ARM/HAND/FINGER HALF LEGS,5001298,CDM,969,RC,SS298,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7363.94,9015,
FACE COMBO 4 MELASMA W/V-IPL,5001300,CDM,969,RC,SS300,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7364.94,9016,
FACE COMBO 4 MELASMA W/V-FR,5001301,CDM,969,RC,SS301,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7365.94,9017,
FACE COMBO 4 DARK CIRCLES,5001302,CDM,969,RC,SS302,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7366.94,9018,
FACE COMBO 5 SCARS W/COLLAGEN BOOSTER,5001303,CDM,969,RC,SS303,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7367.94,9019,
FACE COMBO 3 SCARS W/INTENSE HYDRA,5001304,CDM,969,RC,SS304,HCPCS,OUTPATIENT,,,1600,960,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7368.94,9020,
FACE COMBO 4 ACNE W/SMOOTH,5001305,CDM,969,RC,SS305,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7369.94,9021,
FACE COMBO 4 TEXTURE W/INTENSE HYDRA,5001306,CDM,969,RC,SS306,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7370.94,9022,
FACE COMBO 3 TEXTURE W/INTENSE HYDRA,5001307,CDM,969,RC,SS307,HCPCS,OUTPATIENT,,,1600,960,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7371.94,9023,
FACE COMBO 4 FAT W/INTENSE HYDRA/LIPOELIM,5001308,CDM,969,RC,SS308,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,450,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7372.94,9024,
FACE COMBO 5 FL/WRNKL W/VST W/INTENSE HYDR/COLGN BSTR,5001309,CDM,969,RC,SS309,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7373.94,9025,
FACE COMBO 5 FL/WRNKL W/VFR W/INTENSE HYDR/COLGN BSTR,5001310,CDM,969,RC,SS310,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7374.94,9026,
FACE COMBO 5 SKIN THICK W/VST W/INTENSE HYDRA/COLGN BSTR,5001312,CDM,969,RC,SS312,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7375.94,9027,
FACE COMBO 5 SKIN THICK W/VFR W/INTENSE HYDRA/COLGN BSTR,5001313,CDM,969,RC,SS313,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7376.94,9028,
FACE COMBO 3 SKIN THICK W/INTENSE HYDRA,5001314,CDM,969,RC,SS314,HCPCS,OUTPATIENT,,,1600,960,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7377.94,9029,
FACE COMBO 5 FCL SAG/JOWLS W/INTENSE HYDRA/LIPOELIM/COLGN BS,5001315,CDM,969,RC,SS315,HCPCS,OUTPATIENT,,,650,390,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,650,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7378.94,9030,
FACE COMBO 3 DEHYDRATION W/INTENSE HYDRA,5001316,CDM,969,RC,SS316,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7379.94,9031,
FACE COMBO 2 DEHYDRATION PIE,5001317,CDM,969,RC,SS317,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7380.94,9032,
FACE COMBO 3 OILY SKIN W/SMOOTH,5001318,CDM,969,RC,SS318,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7381.94,9033,
FACE COMBO 2 OILY SKIN LARGE PORES,5001319,CDM,969,RC,SS319,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7382.94,9034,
FACE COMBO 2 ROSACEA,5001320,CDM,969,RC,SS320,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7383.94,9035,
FACE COMBO 2 TELANGIECTASIAS,5001321,CDM,969,RC,SS321,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7384.94,9036,
FACE COMBO 3 PIH COMBO W/VIPL/BRIGHT,5001322,CDM,969,RC,SS322,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7385.94,9037,
FACE COMBO 3 PIH COMBO W/VFR/BRIGHT,5001323,CDM,969,RC,SS323,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7386.94,9038,
BODY COMBO 6 TEXTURE INTENSE HYDRA/COLGN BSTR,5001324,CDM,969,RC,SS324,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7387.94,9039,
BODY COMBO 3 TEXTURE W INTENSE HYDRATION,5001325,CDM,969,RC,SS325,HCPCS,OUTPATIENT,,,1600,960,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7388.94,9040,
BODY COMBO 5 FL/WRNKL W/V-ST W/INTENSE HYDRA/COLGN BSTR,5001326,CDM,969,RC,SS326,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7389.94,9041,
BODY COMBO 5 FL/WRNKL W/V-FR W/INTENSE HYDRA/COLGN BSTR,5001327,CDM,969,RC,SS327,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7390.94,9042,
BODY COMBO 3 FL/WRNKL W/INTENSE HYDRATION,5001328,CDM,969,RC,SS328,HCPCS,OUTPATIENT,,,1600,960,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7391.94,9043,
BODY COMBO 5 SKIN THICK W/V-ST INTENSE HYDRA/COLGN BSTR,5001329,CDM,969,RC,SS329,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7392.94,9044,
BODY COMBO 5 SKIN THICK W/V-FR INTENSE HYDRA/COLGN BSTR,5001330,CDM,969,RC,SS330,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7393.94,9045,
BODY COMBO 3 SKIN THICK W/INTENSE HYDRATION,5001331,CDM,969,RC,SS331,HCPCS,OUTPATIENT,,,1600,960,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7394.94,9046,
BODY COMBO 4 LABIA LAXITY W/V-ST INTENSE HYDRA/COLGN BSTR,5001332,CDM,969,RC,SS332,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7395.94,9047,
BODY COMBO 4 LABIA LAXITY W/V-FR INTENSE HYDRA/COLGN BSTR,5001333,CDM,969,RC,SS333,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7396.94,9048,
BODY COMBO 3 LABIA LIGHTENING W V-IPL/V-FR/BRIGHT,5001334,CDM,969,RC,SS334,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7397.94,9049,
BODY COMBO 2 LABIA LIGHTENING PIE W/V-IPL,5001335,CDM,969,RC,SS335,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7398.94,9050,
BODY COMBO 2 KP COMBO W/SMOOTH/INTENSE HYDRA,5001336,CDM,969,RC,SS336,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7399.94,9051,
BODY COMBO 2 INGROWN HAIRS W/V-IPL HR,5001337,CDM,969,RC,SS337,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,450,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7400.94,9052,
BODY COMBO 2 INGROWN HAIRS W/ELYSION,5001339,CDM,969,RC,SS339,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,450,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7401.94,9053,
COMP BODY 3 SOLAR LENTIGO W/BRIGHT,5001340,CDM,969,RC,SS340,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7402.94,9054,
COMP BODY 2 SOLAR LENTIGO W/BRIGHT,5001341,CDM,969,RC,SS341,HCPCS,OUTPATIENT,,,650,390,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,650,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7403.94,9055,
COMP COMBO 6 SCARS W/INTENSE HYDRA/COLGN BSTR,5001342,CDM,969,RC,SS342,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7404.94,9056,
COMP COMBO 5 SCARS W/INTENSE HYDRATION,5001343,CDM,969,RC,SS343,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7405.94,9057,
COMP COMBO 5 TEXTURE W/COLGN BSTR,5001344,CDM,969,RC,SS344,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7406.94,9058,
COMP COMBO 5 TEXTURE W/INTENSE HYDRATION,5001345,CDM,969,RC,SS345,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7407.94,9059,
COMP COMBO 5 LARGE PORES W/SMOOTH,5001346,CDM,969,RC,SS346,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7408.94,9060,
COMP COMBO 5 WRINKLES W/V-FR W/COLGN BSTR,5001347,CDM,969,RC,SS347,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7409.94,9061,
COMP COMBO 5 WRINKLES W/V-ST W/COLGN BSTR,5001348,CDM,969,RC,SS348,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,700,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7410.94,9062,
COMP COMBO 5 WRINKLES W/V-ST  and V-IPL W/COLGN BSTR,5001349,CDM,969,RC,SS349,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7411.94,9063,
COMP COMBO 5 LAXITY W/V-FORM W/COLGN BSTR,5001350,CDM,969,RC,SS350,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7412.94,9064,
COMP COMBO 5 LAXITY W/V-ST W/COLGN BSTR,5001351,CDM,969,RC,SS351,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,900,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7413.94,9065,
COMP COMBO 4 ACNE W/SMOOTH,5001352,CDM,969,RC,SS352,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,400,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7414.94,9066,
COMP COMBO 4 POIKILODERMA W/BRIGHT,5001353,CDM,969,RC,SS353,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,800,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7415.94,9067,
COMP COMBO 4 OILY SKIN W/SMOOTH,5001354,CDM,969,RC,SS354,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7416.94,9068,
COMP COMBO 3 DEHYDRATION W/INTENSE HYDRA,5001355,CDM,969,RC,SS355,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7417.94,9069,
COMP COMBO 4 SKIN THICKENING W/SMOOTH,5001356,CDM,969,RC,SS356,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2000,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7418.94,9070,
INFUSAPORT FLUSH,5005236,CDM,450,RC,96523,HCPCS,OUTPATIENT,,,135,81,,114.75,85,,91.8,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.45,35.15,,37.96,percent of total billed charges,35.15% of total billed charges,1.33,31.95,,1.064,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,51.3,38,,41.04,percent of total billed charges,38% of total billed charges,43.13,31.95,,34.504,percent of total billed charges,31.95% of total billed charges,7419.94,9071,
"96376 - IV Injection, add same drug",5007760,CDM,260,RC,96376,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,11.5,31.95,,9.2,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,,case rate,pays based on per visit rate,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,7420.94,9072,
"96376 IV Injection, add same drug",5007760,CDM,260,RC,96376,HCPCS,OUTPATIENT,,,10,6,,8.5,85,,6.8,Percent of total billed charges,85% of total billed charges,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.52,35.15,,2.816,percent of total billed charges,35.15% of total billed charges,12.14,31.95,,9.712,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,,case rate,pays based on per visit rate,3.2,31.95,,2.56,percent of total billed charges,31.95% of total billed charges,7421.94,9073,
90785 PHYOCHOTHERAPY COMPLEX INTERACTIVE,5140001,CDM,915,RC,90785,HCPCS,OUTPATIENT,,,180,108,,153,85,,122.4,Percent of total billed charges,85% of total billed charges,90,50,,72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90,50,,72,percent of total billed charges,50% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72,40,,57.6,percent of total billed charges,40% of total billed charges,7422.94,9074,
90791 PSYCH DX EVAL,5140002,CDM,915,RC,90791,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,115,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115,50,,92,percent of total billed charges,50% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92,40,,73.6,percent of total billed charges,40% of total billed charges,7423.94,9075,
90792  PSYCH DX EVAL W/MED SRVCS,5140003,CDM,915,RC,90792,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,115,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115,50,,92,percent of total billed charges,50% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92,40,,73.6,percent of total billed charges,40% of total billed charges,7424.94,9076,
90832 PSYTX W/PT 30 MIN,5140004,CDM,521,RC,90832,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,7425.94,9077,
90833 PSYTX W/PT W/ E/M 30 MIN,5140005,CDM,513,RC,90833,HCPCS,OUTPATIENT,,,194,116.4,,164.9,85,,131.92,Percent of total billed charges,85% of total billed charges,97,50,,77.6,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,97,50,,77.6,percent of total billed charges,50% of total billed charges,61.98,31.95,,49.584,percent of total billed charges,31.95% of total billed charges,61.98,31.95,,49.584,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,73.72,38,,58.976,percent of total billed charges,38% of total billed charges,77.6,40,,62.08,percent of total billed charges,40% of total billed charges,7426.94,9078,
90834 PSYTX W/PT 45 MIN,5140006,CDM,915,RC,90834,HCPCS,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,55,50,,44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,55,50,,44,percent of total billed charges,50% of total billed charges,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44,40,,35.2,percent of total billed charges,40% of total billed charges,7427.94,9079,
90837 PSYTX W/PT 60 MIN,5140007,CDM,521,RC,90837,HCPCS,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,85,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,64.6,38,,51.68,percent of total billed charges,38% of total billed charges,68,40,,54.4,percent of total billed charges,40% of total billed charges,7428.94,9080,
90846 FAMILY PSYTX W/O PT 50 MIN,5140008,CDM,915,RC,90846,HCPCS,OUTPATIENT,,,180,108,,153,85,,122.4,Percent of total billed charges,85% of total billed charges,90,50,,72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90,50,,72,percent of total billed charges,50% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72,40,,57.6,percent of total billed charges,40% of total billed charges,7429.94,9081,
90847 FAMILY PSYTX W/PT 50 MIN,5140009,CDM,915,RC,90847,HCPCS,OUTPATIENT,,,180,108,,153,85,,122.4,Percent of total billed charges,85% of total billed charges,90,50,,72,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,90,50,,72,percent of total billed charges,50% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,57.51,31.95,,46.008,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72,40,,57.6,percent of total billed charges,40% of total billed charges,7430.94,9082,
90853 GR PSYCHOTHY CHARGE,5140010,CDM,915,RC,90853,HCPCS,OUTPATIENT,,,209,125.4,,177.65,85,,142.12,Percent of total billed charges,85% of total billed charges,270.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,270.78,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,66.78,31.95,,53.424,percent of total billed charges,31.95% of total billed charges,66.78,31.95,,53.424,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,83.6,40,,66.88,percent of total billed charges,40% of total billed charges,7431.94,9083,
"Complex Uroflowmetry (eg, Calibrated Electronic Equipment) C",5140011,CDM,977,RC,51741,HCPCS,OUTPATIENT,,,25,15,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,5.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7432.94,9084,
MEAS POST-VOIDG RESIDUAL URINE BY US,5140012,CDM,977,RC,51798,HCPCS,OUTPATIENT,,,51,30.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,19.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,9.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7433.94,9085,
Bladder Scan PVR POC,5140012,CDM,982,RC,51798,HCPCS,OUTPATIENT,,,51,30.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,19.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,9.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7434.94,9086,
51720 BLADDER INSTILLATION,5140013,CDM,982,RC,51720,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7435.94,9087,
Insert Temp Indwelling Bladder Cath Complicated,5140014,CDM,983,RC,51703,HCPCS,OUTPATIENT,,,364,218.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,218.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7436.94,9088,
51705 Change Cystostomy Tube Simple PF,5140015,CDM,982,RC,51705,HCPCS,OUTPATIENT,,,255,153,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7437.94,9089,
Simple Cystometrogram (CMG),5140018,CDM,982,RC,52281,HCPCS,OUTPATIENT,,,755,453,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,488.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,143.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7438.94,9090,
Cystoscopy w/Simple Removal,5140019,CDM,983,RC,52310,HCPCS,OUTPATIENT,,,680,408,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,442.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,143.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7439.94,9091,
99223 Initial Inpt/Obsv Care (75 minutes),5140020,CDM,982,RC,99223,HCPCS,OUTPATIENT,,,592,355.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7440.94,9092,
99222 Initial Inpt/Obsv Care (55 minutes),5140021,CDM,982,RC,99222,HCPCS,OUTPATIENT,,,404,242.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7441.94,9093,
99221 Initial Inpt/Obsv Care (40 minutes),5140022,CDM,982,RC,99221,HCPCS,OUTPATIENT,,,297,178.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,104.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7442.94,9094,
Eligard/ Leuprolide acetate suspnsion,5140023,CDM,636,RC,J9217,HCPCS,OUTPATIENT,,,688,412.8,,584.8,85,,467.84,Percent of total billed charges,85% of total billed charges,250.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,250.47,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,241.83,35.15,,,fee schedule,35.15% of LA custom fee schedule,219.82,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,431.4,100,,,case rate,pays based on per visit rate,219.82,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7443.94,9095,
"96402 CHEMO ADMIN, SUBCUT OR IM, HORMONAL",5140024,CDM,521,RC,96402,HCPCS,OUTPATIENT,,,87,52.2,,73.95,85,,59.16,Percent of total billed charges,85% of total billed charges,231.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,231.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,27.8,31.95,,22.24,percent of total billed charges,31.95% of total billed charges,27.8,31.95,,22.24,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,33.06,38,,26.448,percent of total billed charges,38% of total billed charges,34.8,40,,27.84,percent of total billed charges,40% of total billed charges,7444.94,9096,
76872 Ultrasound transrectal,5140025,CDM,521,RC,76872,HCPCS,OUTPATIENT,,,355,213,,301.75,85,,241.4,Percent of total billed charges,85% of total billed charges,232.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,232.55,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,113.42,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,113.42,31.95,,90.736,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,134.9,38,,107.92,percent of total billed charges,38% of total billed charges,142,40,,113.6,percent of total billed charges,40% of total billed charges,7445.94,9097,
EKG Interpretation Only,5140026,CDM,521,RC,93010,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,59.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,59.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,7446.94,9098,
93010 EKG POC,5140026,CDM,521,RC,93010,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,59.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,59.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,12,40,,9.6,percent of total billed charges,40% of total billed charges,7447.94,9099,
"96372 Therapeutic, prophylactic, or diagnostic injections",5140027,CDM,260,RC,96372,HCPCS,OUTPATIENT,,,30,18,59,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,78.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,78.94,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,10.55,35.15,,8.44,percent of total billed charges,35.15% of total billed charges,26.84,31.95,,21.472,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,175,100,,,case rate,pays based on per visit rate,9.59,31.95,,7.672,percent of total billed charges,31.95% of total billed charges,7448.94,9100,
90744 Hepatitis B - Engerix 0.5 mL - Peds,5140028,CDM,521,RC,90744,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,44.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,44.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,24.7,38,,19.76,percent of total billed charges,38% of total billed charges,26,40,,20.8,percent of total billed charges,40% of total billed charges,7449.94,9101,
Ear Irrigation POC,5140030,CDM,521,RC,69209,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,235.32,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,235.32,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,7.99,31.95,,6.392,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,9.5,38,,7.6,percent of total billed charges,38% of total billed charges,10,40,,8,percent of total billed charges,40% of total billed charges,7450.94,9102,
"Hepatitis B Vaccine, Pediatric 3 Dose Sched POC",5140032,CDM,636,RC,90744,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,44.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,44.93,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,22.85,35.15,,,fee schedule,35.15% of LA custom fee schedule,20.77,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,77.63,100,,,case rate,pays based on per visit rate,20.77,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7451.94,9103,
Hearing Test POC,5140033,CDM,521,RC,92551,HCPCS,OUTPATIENT,,,21,12.6,,17.85,85,,14.28,Percent of total billed charges,85% of total billed charges,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,10.5,50,,8.4,percent of total billed charges,50% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,7.98,38,,6.384,percent of total billed charges,38% of total billed charges,8.4,40,,6.72,percent of total billed charges,40% of total billed charges,7452.94,9104,
Vision Testing,5140034,CDM,521,RC,99173,HCPCS,OUTPATIENT,,,6,3.6,,5.1,85,,4.08,Percent of total billed charges,85% of total billed charges,3,50,,2.4,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,3,50,,2.4,percent of total billed charges,50% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,1.92,31.95,,1.536,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,2.28,38,,1.824,percent of total billed charges,38% of total billed charges,2.4,40,,1.92,percent of total billed charges,40% of total billed charges,7453.94,9105,
Rapid Strep POC,5140035,CDM,306,RC,87880,HCPCS,OUTPATIENT,,,30,18,,25.5,85,,20.4,Percent of total billed charges,85% of total billed charges,55.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.8,110,,,fee schedule,110% of LA custom fee schedule,16.18,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,11.4,38,,9.12,percent of total billed charges,38% of total billed charges,16.18,100,,,Fee Schedule,100% of LA custom fee schedule,7454.94,9106,
REMOVE IMPACTED EAR WAX UNI,5140036,CDM,521,RC,69210,HCPCS,OUTPATIENT,,,107,64.2,,90.95,85,,72.76,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,34.19,31.95,,27.352,percent of total billed charges,31.95% of total billed charges,34.19,31.95,,27.352,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,40.66,38,,32.528,percent of total billed charges,38% of total billed charges,42.8,40,,34.24,percent of total billed charges,40% of total billed charges,7455.94,9107,
EKG POC,5140050,CDM,521,RC,93005,HCPCS,OUTPATIENT,,,55,33,,46.75,85,,37.4,Percent of total billed charges,85% of total billed charges,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,17.57,31.95,,14.056,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,20.9,38,,16.72,percent of total billed charges,38% of total billed charges,22,40,,17.6,percent of total billed charges,40% of total billed charges,7456.94,9108,
Rapid Flu AB POC,5140052,CDM,300,RC,87804,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,55.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.8,110,,,fee schedule,110% of LA custom fee schedule,16.18,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,10.64,percent of total billed charges,38% of total billed charges,16.18,100,,,Fee Schedule,100% of LA custom fee schedule,7457.94,9109,
Rapid Flu AB POC,5140052,CDM,300,RC,87804,HCPCS,OUTPATIENT,,,35,21,,29.75,85,,23.8,Percent of total billed charges,85% of total billed charges,55.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,55.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.8,110,,,fee schedule,110% of LA custom fee schedule,16.18,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,13.3,38,,10.64,percent of total billed charges,38% of total billed charges,16.18,100,,,Fee Schedule,100% of LA custom fee schedule,7458.94,9110,
Helicobacter Pylori POC,5140053,CDM,300,RC,86318,HCPCS,OUTPATIENT,,,25,15,,21.25,85,,17,Percent of total billed charges,85% of total billed charges,60.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,60.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,17.11,110,,,fee schedule,110% of LA custom fee schedule,15.55,100,,,fee schedule,100% of LA custom fee schedule,,,,,other,Not separately reimbursable,9.5,38,,7.6,percent of total billed charges,38% of total billed charges,15.55,100,,,Fee Schedule,100% of LA custom fee schedule,7459.94,9111,
Debride of Nail(s) By Any Method(s); Six or More Charge,5140054,CDM,521,RC,11721,HCPCS,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,95,38,,76,percent of total billed charges,38% of total billed charges,100,40,,80,percent of total billed charges,40% of total billed charges,7460.94,9112,
11721  Debride of Nail(s) By Any Method(s); Six or More,5140054,CDM,521,RC,11721,HCPCS,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,95,38,,76,percent of total billed charges,38% of total billed charges,100,40,,80,percent of total billed charges,40% of total billed charges,7461.94,9113,
Debride Nail(s) By Any Method(s); 1 to 5,5140055,CDM,521,RC,11720,HCPCS,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,38.98,31.95,,31.184,percent of total billed charges,31.95% of total billed charges,38.98,31.95,,31.184,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,46.36,38,,37.088,percent of total billed charges,38% of total billed charges,48.8,40,,39.04,percent of total billed charges,40% of total billed charges,7462.94,9114,
"Trimming of nondystrophic nails, any",5140055,CDM,521,RC,11719,HCPCS,OUTPATIENT,,,122,73.2,,103.7,85,,82.96,Percent of total billed charges,85% of total billed charges,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,188.07,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,38.98,31.95,,31.184,percent of total billed charges,31.95% of total billed charges,38.98,31.95,,31.184,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,46.36,38,,37.088,percent of total billed charges,38% of total billed charges,48.8,40,,39.04,percent of total billed charges,40% of total billed charges,7463.94,9115,
APPLICATION SHORT ARM SPLINT,5140056,CDM,521,RC,29125,HCPCS,OUTPATIENT,,,77,46.2,,65.45,85,,52.36,Percent of total billed charges,85% of total billed charges,383.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,383.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.6,31.95,,19.68,percent of total billed charges,31.95% of total billed charges,24.6,31.95,,19.68,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,29.26,38,,23.408,percent of total billed charges,38% of total billed charges,30.8,40,,24.64,percent of total billed charges,40% of total billed charges,7464.94,9116,
APPLICATION FINGER SPLINT,5140057,CDM,521,RC,29130,HCPCS,OUTPATIENT,,,112,67.2,,95.2,85,,76.16,Percent of total billed charges,85% of total billed charges,235.32,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,235.32,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,35.78,31.95,,28.624,percent of total billed charges,31.95% of total billed charges,35.78,31.95,,28.624,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,42.56,38,,34.048,percent of total billed charges,38% of total billed charges,44.8,40,,35.84,percent of total billed charges,40% of total billed charges,7465.94,9117,
Paring or Cutting Benign Hyperkeratotic Lesion,5140058,CDM,521,RC,11056,HCPCS,OUTPATIENT,,,168,100.8,,142.8,85,,114.24,Percent of total billed charges,85% of total billed charges,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,212.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,53.68,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,53.68,31.95,,42.944,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,63.84,38,,51.072,percent of total billed charges,38% of total billed charges,67.2,40,,53.76,percent of total billed charges,40% of total billed charges,7466.94,9118,
"Avulsion of Nail Plate, Partial or Complete, Simple; Single",5140059,CDM,521,RC,11730,HCPCS,OUTPATIENT,,,295,177,,250.75,85,,200.6,Percent of total billed charges,85% of total billed charges,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,265.43,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,94.25,31.95,,75.4,percent of total billed charges,31.95% of total billed charges,94.25,31.95,,75.4,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,112.1,38,,89.68,percent of total billed charges,38% of total billed charges,118,40,,94.4,percent of total billed charges,40% of total billed charges,7467.94,9119,
11042 Debride Skin/Soft Tissue Charge -CLINIC,5140060,CDM,521,RC,11042,HCPCS,OUTPATIENT,,,150,90,,127.5,85,,102,Percent of total billed charges,85% of total billed charges,1307.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1307.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,47.93,31.95,,38.344,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,57,38,,45.6,percent of total billed charges,38% of total billed charges,60,40,,48,percent of total billed charges,40% of total billed charges,7468.94,9120,
URINALYSIS AUTO W/O SCOPE,5140061,CDM,982,RC,81003,HCPCS,OUTPATIENT,,,15,9,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2.25,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7469.94,9121,
81003 URINALYSIS AUTO W/O SCOPE,5140061,CDM,521,RC,81003,HCPCS,OUTPATIENT,,,15,9,,12.75,85,,10.2,Percent of total billed charges,85% of total billed charges,10.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,10.48,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,4.79,31.95,,3.832,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,5.7,38,,4.56,percent of total billed charges,38% of total billed charges,6,40,,4.8,percent of total billed charges,40% of total billed charges,7470.94,9122,
"10060 Drain Skin Abscess, Simple/Single Charge-Clinic",5140062,CDM,521,RC,10060,HCPCS,OUTPATIENT,,,198,118.8,,168.3,85,,134.64,Percent of total billed charges,85% of total billed charges,495.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,495.68,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.26,31.95,,50.608,percent of total billed charges,31.95% of total billed charges,63.26,31.95,,50.608,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,75.24,38,,60.192,percent of total billed charges,38% of total billed charges,79.2,40,,63.36,percent of total billed charges,40% of total billed charges,7471.94,9123,
93000 Electrocardiogram complete,5140063,CDM,521,RC,93000,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,164.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,164.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,19,38,,15.2,percent of total billed charges,38% of total billed charges,20,40,,16,percent of total billed charges,40% of total billed charges,7472.94,9124,
BH Established Visit Level 2 99212,5140201,CDM,521,RC,99212,HCPCS,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,32,40,,25.6,percent of total billed charges,40% of total billed charges,7473.94,9125,
BH Established Visit Level 3 99213,5140202,CDM,521,RC,99213,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,7474.94,9126,
BH Established Visit Level 4 99214,5140203,CDM,521,RC,99214,HCPCS,OUTPATIENT,,,153,91.8,,130.05,85,,104.04,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,48.88,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,48.88,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,58.14,38,,46.512,percent of total billed charges,38% of total billed charges,61.2,40,,48.96,percent of total billed charges,40% of total billed charges,7475.94,9127,
BH Established Visit Level 5 99215,5140204,CDM,521,RC,99215,HCPCS,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,82.08,38,,65.664,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,7476.94,9128,
BH New Visit Level 2 99202,5140206,CDM,915,RC,99202,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.2,40,,31.36,percent of total billed charges,40% of total billed charges,7477.94,9129,
BH New Visit Level 3 99203,5140207,CDM,915,RC,99203,HCPCS,OUTPATIENT,,,149,89.4,,126.65,85,,101.32,Percent of total billed charges,85% of total billed charges,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,59.6,40,,47.68,percent of total billed charges,40% of total billed charges,7478.94,9130,
BH New Visit Level 4 99204,5140208,CDM,915,RC,99204,HCPCS,OUTPATIENT,,,255,153,,216.75,85,,173.4,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,102,40,,81.6,percent of total billed charges,40% of total billed charges,7479.94,9131,
BH New Visit Level 5 99205,5140209,CDM,915,RC,99205,HCPCS,OUTPATIENT,,,329,197.4,,279.65,85,,223.72,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.12,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,105.12,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.6,40,,105.28,percent of total billed charges,40% of total billed charges,7480.94,9132,
PSYCL/NRPSYC TEST ADMIN TECH 1ST 30 MIN,5140210,CDM,915,RC,96138,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,58.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,58.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,26,40,,20.8,percent of total billed charges,40% of total billed charges,7481.94,9133,
PSYCL/NRPSYC TEST ADMIN TECH EA ADD 30 MIN,5140211,CDM,915,RC,96139,HCPCS,OUTPATIENT,,,65,39,,55.25,85,,44.2,Percent of total billed charges,85% of total billed charges,140.18,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,140.18,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,20.77,31.95,,16.616,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,26,40,,20.8,percent of total billed charges,40% of total billed charges,7482.94,9134,
HEALTH BEHAVIOR ASSESSMENT,5140212,CDM,915,RC,96156,HCPCS,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,266,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,266,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,68,40,,54.4,percent of total billed charges,40% of total billed charges,7483.94,9135,
HLTH BHV INTRVNT INDIV 1ST 30 MIN,5140213,CDM,915,RC,96158,HCPCS,OUTPATIENT,,,115,69,,97.75,85,,78.2,Percent of total billed charges,85% of total billed charges,266,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,266,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,36.74,31.95,,29.392,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46,40,,36.8,percent of total billed charges,40% of total billed charges,7484.94,9136,
HLTH BHV INTRVNT INDIV EA ADD 15 MIN,5140214,CDM,915,RC,96159,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,18,40,,14.4,percent of total billed charges,40% of total billed charges,7485.94,9137,
HLTH BHV INTRVNT FAM 1ST 30 MIN,5140215,CDM,915,RC,96167,HCPCS,OUTPATIENT,,,125,75,,106.25,85,,85,Percent of total billed charges,85% of total billed charges,92.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,92.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,39.94,31.95,,31.952,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50,40,,40,percent of total billed charges,40% of total billed charges,7486.94,9138,
HLTH BHV INTRVNT FAM EA ADD 15 MIN,5140216,CDM,915,RC,96168,HCPCS,OUTPATIENT,,,45,27,,38.25,85,,30.6,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,14.38,31.95,,11.504,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,18,40,,14.4,percent of total billed charges,40% of total billed charges,7487.94,9139,
HLTH BHV INTRVNT FAM W/O PT 1ST 30 MIN,5140217,CDM,915,RC,96170,HCPCS,OUTPATIENT,,,140,84,,119,85,,95.2,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,56,40,,44.8,percent of total billed charges,40% of total billed charges,7488.94,9140,
HLTH BHV INTRVNT FAM W/O PT EA ADD 15 MIN,5140218,CDM,915,RC,96171,HCPCS,OUTPATIENT,,,50,30,,42.5,85,,34,Percent of total billed charges,85% of total billed charges,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,0.01,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,15.98,31.95,,12.784,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20,40,,16,percent of total billed charges,40% of total billed charges,7489.94,9141,
CRISIS STABILIZATION - INDIVIDUAL,5140219,CDM,915,RC,H0045,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,100,50,,80,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,100,50,,80,percent of total billed charges,50% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,80,40,,64,percent of total billed charges,40% of total billed charges,7490.94,9142,
CRISIS INTERVENTION FOLLOW UP,5140220,CDM,915,RC,H2011,HCPCS,OUTPATIENT,,,75,45,,63.75,85,,51,Percent of total billed charges,85% of total billed charges,37.5,50,,30,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,37.5,50,,30,percent of total billed charges,50% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,23.96,31.95,,19.168,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30,40,,24,percent of total billed charges,40% of total billed charges,7491.94,9143,
CRISIS INTERVENTION PER DIEM,5140221,CDM,915,RC,S9485,HCPCS,OUTPATIENT,,,400,240,,340,85,,272,Percent of total billed charges,85% of total billed charges,200,50,,160,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,200,50,,160,percent of total billed charges,50% of total billed charges,127.8,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,127.8,31.95,,102.24,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160,40,,128,percent of total billed charges,40% of total billed charges,7492.94,9144,
PSYTX W/PT W/ E/M 45 MIN,5140222,CDM,915,RC,90836,HCPCS,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,87.5,50,,70,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,87.5,50,,70,percent of total billed charges,50% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70,40,,56,percent of total billed charges,40% of total billed charges,7493.94,9145,
PSYTX W/PT W/ E/M 60 MIN,5140223,CDM,915,RC,90838,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,115,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115,50,,92,percent of total billed charges,50% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92,40,,73.6,percent of total billed charges,40% of total billed charges,7494.94,9146,
Psycl/Nrpsyc Test Admin by Phys/QHP 1st 30 Min,5140224,CDM,521,RC,96136,HCPCS,OUTPATIENT,,,90,54,,76.5,85,,61.2,Percent of total billed charges,85% of total billed charges,58.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,58.15,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,28.76,31.95,,23.008,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,34.2,38,,27.36,percent of total billed charges,38% of total billed charges,36,40,,28.8,percent of total billed charges,40% of total billed charges,7495.94,9147,
Psycl/Nrpsyc Test Admin by Phys/QHP Ea Add 30 Min,5140225,CDM,521,RC,96137,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,167.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,167.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,7496.94,9148,
96130 Psycl Testing Eval Phys/QHP 1st Hour,5140226,CDM,521,RC,96130,HCPCS,OUTPATIENT,,,235,141,,199.75,85,,159.8,Percent of total billed charges,85% of total billed charges,460.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,460.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,75.08,31.95,,60.064,percent of total billed charges,31.95% of total billed charges,75.08,31.95,,60.064,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,89.3,38,,71.44,percent of total billed charges,38% of total billed charges,94,40,,75.2,percent of total billed charges,40% of total billed charges,7497.94,9149,
96131 Psycl Testing Eval Phys/QHP Ea Add Hour,5140227,CDM,521,RC,96131,HCPCS,OUTPATIENT,,,175,105,,148.75,85,,119,Percent of total billed charges,85% of total billed charges,360.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,360.24,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,55.91,31.95,,44.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,66.5,38,,53.2,percent of total billed charges,38% of total billed charges,70,40,,56,percent of total billed charges,40% of total billed charges,7498.94,9150,
96132 Nrpsyc Testing Eval Phys/QHP 1st Hour,5140228,CDM,521,RC,96132,HCPCS,OUTPATIENT,,,255,153,,216.75,85,,173.4,Percent of total billed charges,85% of total billed charges,460.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,460.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,96.9,38,,77.52,percent of total billed charges,38% of total billed charges,102,40,,81.6,percent of total billed charges,40% of total billed charges,7499.94,9151,
96133 Nrpsyc Testing Eval Phys/QHP Ea Add Hour,5140229,CDM,521,RC,96133,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,401.67,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,401.67,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,63.9,31.95,,51.12,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,76,38,,60.8,percent of total billed charges,38% of total billed charges,80,40,,64,percent of total billed charges,40% of total billed charges,7500.94,9152,
90791 PSYCH DX EVAL NH,5140230,CDM,525,RC,90791,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,115,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115,50,,92,percent of total billed charges,50% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,92,40,,73.6,percent of total billed charges,40% of total billed charges,7501.94,9153,
90792 PSYCH DX EVAL W/MED SRVCS NH,5140231,CDM,525,RC,90792,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,115,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115,50,,92,percent of total billed charges,50% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,92,40,,73.6,percent of total billed charges,40% of total billed charges,7502.94,9154,
90832 PSYTX W/PT 30 MIN NH,5140232,CDM,525,RC,90832,HCPCS,OUTPATIENT,,,85,51,,72.25,85,,57.8,Percent of total billed charges,85% of total billed charges,42.5,50,,34,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,42.5,50,,34,percent of total billed charges,50% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,27.16,31.95,,21.728,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,32.3,38,,25.84,percent of total billed charges,38% of total billed charges,34,40,,27.2,percent of total billed charges,40% of total billed charges,7503.94,9155,
90834 PSYTX W/PT 45 MIN NH,5140234,CDM,525,RC,90834,HCPCS,OUTPATIENT,,,110,66,,93.5,85,,74.8,Percent of total billed charges,85% of total billed charges,55,50,,44,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,55,50,,44,percent of total billed charges,50% of total billed charges,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,35.15,31.95,,28.12,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,41.8,38,,33.44,percent of total billed charges,38% of total billed charges,44,40,,35.2,percent of total billed charges,40% of total billed charges,7504.94,9156,
90837 PSYTX W/PT 60 MIN NH,5140237,CDM,525,RC,90837,HCPCS,OUTPATIENT,,,170,102,,144.5,85,,115.6,Percent of total billed charges,85% of total billed charges,85,50,,68,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,85,50,,68,percent of total billed charges,50% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,54.32,31.95,,43.456,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,64.6,38,,51.68,percent of total billed charges,38% of total billed charges,68,40,,54.4,percent of total billed charges,40% of total billed charges,7505.94,9157,
90839 PSYTX CRISIS INITIAL 60 MIN NH,5140239,CDM,525,RC,90839,HCPCS,OUTPATIENT,,,230,138,,195.5,85,,156.4,Percent of total billed charges,85% of total billed charges,115,50,,92,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,115,50,,92,percent of total billed charges,50% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,73.49,31.95,,58.792,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,87.4,38,,69.92,percent of total billed charges,38% of total billed charges,92,40,,73.6,percent of total billed charges,40% of total billed charges,7506.94,9158,
90845 PSYCHOANALYSIS NH,5140245,CDM,525,RC,90845,HCPCS,OUTPATIENT,,,140,84,,119,85,,95.2,Percent of total billed charges,85% of total billed charges,70,50,,56,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,70,50,,56,percent of total billed charges,50% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,44.73,31.95,,35.784,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,53.2,38,,42.56,percent of total billed charges,38% of total billed charges,56,40,,44.8,percent of total billed charges,40% of total billed charges,7507.94,9159,
BH Est Visit Level 2 99212 NH,5140262,CDM,525,RC,99212,HCPCS,OUTPATIENT,,,80,48,,68,85,,54.4,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,25.56,31.95,,20.448,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,30.4,38,,24.32,percent of total billed charges,38% of total billed charges,32,40,,25.6,percent of total billed charges,40% of total billed charges,7508.94,9160,
BH Est Visit Level 3 99213 NH,5140263,CDM,525,RC,99213,HCPCS,OUTPATIENT,,,100,60,,85,85,,68,Percent of total billed charges,85% of total billed charges,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,31.95,31.95,,25.56,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,38,38,,30.4,percent of total billed charges,38% of total billed charges,40,40,,32,percent of total billed charges,40% of total billed charges,7509.94,9161,
BH Est Visit Level 4 99214 NH,5140264,CDM,525,RC,99214,HCPCS,OUTPATIENT,,,153,91.8,,130.05,85,,104.04,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,48.88,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,48.88,31.95,,39.104,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,58.14,38,,46.512,percent of total billed charges,38% of total billed charges,61.2,40,,48.96,percent of total billed charges,40% of total billed charges,7510.94,9162,
BH Est Visit Level 5 99215 NH,5140265,CDM,525,RC,99215,HCPCS,OUTPATIENT,,,216,129.6,,183.6,85,,146.88,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,69.01,31.95,,55.208,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,82.08,38,,65.664,percent of total billed charges,38% of total billed charges,86.4,40,,69.12,percent of total billed charges,40% of total billed charges,7511.94,9163,
BH New Visit Level 2 99202 NH,5140267,CDM,525,RC,99202,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,31.31,31.95,,25.048,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,37.24,38,,29.792,percent of total billed charges,38% of total billed charges,39.2,40,,31.36,percent of total billed charges,40% of total billed charges,7512.94,9164,
BH New Visit Level 3 99203 NH,5140268,CDM,525,RC,99203,HCPCS,OUTPATIENT,,,149,89.4,,126.65,85,,101.32,Percent of total billed charges,85% of total billed charges,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,47.61,31.95,,38.088,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,56.62,38,,45.296,percent of total billed charges,38% of total billed charges,59.6,40,,47.68,percent of total billed charges,40% of total billed charges,7513.94,9165,
BH New Visit Level 4 99204 NH,5140269,CDM,525,RC,99204,HCPCS,OUTPATIENT,,,255,153,,216.75,85,,173.4,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,81.47,31.95,,65.176,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,96.9,38,,77.52,percent of total billed charges,38% of total billed charges,102,40,,81.6,percent of total billed charges,40% of total billed charges,7514.94,9166,
BH New Visit Level 5 99205 NH,5140270,CDM,525,RC,99205,HCPCS,OUTPATIENT,,,329,197.4,,279.65,85,,223.72,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,105.12,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,105.12,31.95,,84.096,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,125.02,38,,100.016,percent of total billed charges,38% of total billed charges,131.6,40,,105.28,percent of total billed charges,40% of total billed charges,7515.94,9167,
OP New Visit Level 2 99202,5560002,CDM,510,RC,99202,HCPCS,OUTPATIENT,,,98,58.8,,83.3,85,,66.64,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,,fee schedule,110% of LA custom fee schedule,32.87,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,37.24,38,,29.792,percent of total billed charges,38% of total billed charges,32.87,100,,,Fee Schedule,100% of LA custom fee schedule,7516.94,9168,
OP New Visit Level 3 99203,5560003,CDM,510,RC,99203,HCPCS,OUTPATIENT,,,149,89.4,,126.65,85,,101.32,Percent of total billed charges,85% of total billed charges,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,41.61,110,,,fee schedule,110% of LA custom fee schedule,37.83,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,56.62,38,,45.296,percent of total billed charges,38% of total billed charges,37.83,100,,,Fee Schedule,100% of LA custom fee schedule,7517.94,9169,
OP New Visit Level 4 99204,5560004,CDM,510,RC,99204,HCPCS,OUTPATIENT,,,255,153,,216.75,85,,173.4,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.45,110,,,fee schedule,110% of LA custom fee schedule,56.77,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,96.9,38,,77.52,percent of total billed charges,38% of total billed charges,56.77,100,,,Fee Schedule,100% of LA custom fee schedule,7518.94,9170,
OP New Visit Level 5 99205,5560005,CDM,510,RC,99205,HCPCS,OUTPATIENT,,,329,197.4,,279.65,85,,223.72,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.45,110,,,fee schedule,110% of LA custom fee schedule,56.77,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,125.02,38,,100.016,percent of total billed charges,38% of total billed charges,56.77,100,,,Fee Schedule,100% of LA custom fee schedule,7519.94,9171,
OP Est Visit Level 1 99211,5560006,CDM,510,RC,99211,HCPCS,OUTPATIENT,,,171,102.6,,145.35,85,,116.28,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,,fee schedule,110% of LA custom fee schedule,32.87,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,64.98,38,,51.984,percent of total billed charges,38% of total billed charges,32.87,100,,,Fee Schedule,100% of LA custom fee schedule,7520.94,9172,
OP Est Visit Level 2 99212,5560007,CDM,510,RC,99212,HCPCS,OUTPATIENT,,,200,120,,170,85,,136,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,,fee schedule,110% of LA custom fee schedule,32.87,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,76,38,,60.8,percent of total billed charges,38% of total billed charges,32.87,100,,,Fee Schedule,100% of LA custom fee schedule,7521.94,9173,
OP Est Visit Level 3 99213,5560008,CDM,510,RC,99213,HCPCS,OUTPATIENT,,,226,135.6,,192.1,85,,153.68,Percent of total billed charges,85% of total billed charges,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,204.05,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,41.61,110,,,fee schedule,110% of LA custom fee schedule,37.83,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,85.88,38,,68.704,percent of total billed charges,38% of total billed charges,37.83,100,,,Fee Schedule,100% of LA custom fee schedule,7522.94,9174,
OP Est Visit Level 4 99214,5560009,CDM,510,RC,99214,HCPCS,OUTPATIENT,,,300,180,,255,85,,204,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.45,110,,,fee schedule,110% of LA custom fee schedule,56.77,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,114,38,,91.2,percent of total billed charges,38% of total billed charges,56.77,100,,,Fee Schedule,100% of LA custom fee schedule,7523.94,9175,
OP Est Visit Level 5 99215,5560010,CDM,510,RC,99215,HCPCS,OUTPATIENT,,,335,201,,284.75,85,,227.8,Percent of total billed charges,85% of total billed charges,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,296.91,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,62.45,110,,,fee schedule,110% of LA custom fee schedule,56.77,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,127.3,38,,101.84,percent of total billed charges,38% of total billed charges,56.77,100,,,Fee Schedule,100% of LA custom fee schedule,7524.94,9176,
HOS OP CLIN VISIT ASSESS  MGMT PT,5560011,CDM,510,RC,G0463,HCPCS,OUTPATIENT,,,213,127.8,,181.05,85,,144.84,Percent of total billed charges,85% of total billed charges,313.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,313.37,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,68.05,31.95,,54.44,percent of total billed charges,31.95% of total billed charges,68.05,31.95,,54.44,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,80.94,38,,64.752,percent of total billed charges,38% of total billed charges,85.2,40,,68.16,percent of total billed charges,40% of total billed charges,7525.94,9177,
Post OP Global Facility Charge,5560012,CDM,510,RC,99212,HCPCS,OUTPATIENT,,,62,37.2,,52.7,85,,42.16,Percent of total billed charges,85% of total billed charges,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,177.36,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.16,110,,,fee schedule,110% of LA custom fee schedule,32.87,100,,,fee schedule,100% of LA custom fee schedule,160.45,100,,,case rate,pays based on per visit rate,23.56,38,,18.848,percent of total billed charges,38% of total billed charges,32.87,100,,,Fee Schedule,100% of LA custom fee schedule,7526.94,9178,
OP Procedure Level 1,5560040,CDM,361,RC,,,OUTPATIENT,,,250,150,,212.5,85,,170,Percent of total billed charges,85% of total billed charges,125,50,,100,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,125,50,,100,percent of total billed charges,50% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,79.88,31.95,,63.904,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,38,,76,percent of total billed charges,38% of total billed charges,100,40,,80,percent of total billed charges,40% of total billed charges,7527.94,9179,
OP Procedure Level 2,5560041,CDM,361,RC,,,OUTPATIENT,,,500,300,,425,85,,340,Percent of total billed charges,85% of total billed charges,250,50,,200,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,250,50,,200,percent of total billed charges,50% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,159.75,31.95,,127.8,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,190,38,,152,percent of total billed charges,38% of total billed charges,200,40,,160,percent of total billed charges,40% of total billed charges,7528.94,9180,
OP Procedure Level 3,5560042,CDM,361,RC,,,OUTPATIENT,,,1200,720,,1020,85,,816,Percent of total billed charges,85% of total billed charges,600,50,,480,percent of total billed charges,50% of total billed charges,,,,,other ,Not separately reimbursable,600,50,,480,percent of total billed charges,50% of total billed charges,383.4,31.95,,306.72,percent of total billed charges,31.95% of total billed charges,383.4,31.95,,306.72,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,456,38,,364.8,percent of total billed charges,38% of total billed charges,480,40,,384,percent of total billed charges,40% of total billed charges,7529.94,9181,
OP Prof Procedure Level 1,5560070,CDM,978,RC,,,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7530.94,9182,
OP Prof Procedure Level 2,5560071,CDM,978,RC,,,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7531.94,9183,
OP Prof Procedure Level 3,5560072,CDM,978,RC,,,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7532.94,9184,
99202 Office/OP New Visit Level 2,5560081,CDM,978,RC,99202,HCPCS,OUTPATIENT,,,202,121.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7533.94,9185,
99203 Office/OP New Visit Level 3,5560082,CDM,978,RC,99203,HCPCS,OUTPATIENT,,,306,183.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7534.94,9186,
99204 Office/OP New Visit Level 4,5560083,CDM,978,RC,99204,HCPCS,OUTPATIENT,,,474,284.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7535.94,9187,
99205 Office/OP New Visit Level 5,5560084,CDM,978,RC,99205,HCPCS,OUTPATIENT,,,590,354,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,208.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,172.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7536.94,9188,
99211 Office/OP Established Visit Level 1,5560085,CDM,978,RC,99211,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7537.94,9189,
99212 Office/OP Established  Visit Level 2,5560086,CDM,978,RC,99212,HCPCS,OUTPATIENT,,,124,74.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7538.94,9190,
99213 Office/OP Established Visit Level 3,5560087,CDM,978,RC,99213,HCPCS,OUTPATIENT,,,208,124.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,62.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7539.94,9191,
99214 Office/OP Established  Visit Level 4,5560088,CDM,978,RC,99214,HCPCS,OUTPATIENT,,,306,183.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7540.94,9192,
99215 Office/OP Established  Visit Level 5,5560089,CDM,978,RC,99215,HCPCS,OUTPATIENT,,,410,246,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7541.94,9193,
OP Prof Procedure Level 1 Ortho,5560090,CDM,978,RC,,,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7542.94,9194,
OP Prof Procedure Level 2 Ortho,5560091,CDM,978,RC,,,OUTPATIENT,,,850,510,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7543.94,9195,
OP Prof Procedure Level 3 Ortho,5560092,CDM,978,RC,,,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7544.94,9196,
99242 Outpatient Consult Level 2,5560092,CDM,978,RC,99242,HCPCS,OUTPATIENT,,,206,123.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7545.94,9197,
23615 OPEN TX PROXIMAL HUMERAL FRACTURE,5560100,CDM,975,RC,23615,HCPCS,OUTPATIENT,,,2750,1650,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1381.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,838.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7546.94,9198,
25505 CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION,5560101,CDM,975,RC,25505,HCPCS,OUTPATIENT,,,1400,840,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,758.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,443.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7547.94,9199,
25515 OPEN TX RADIAL SHAFT FRACTURE,5560102,CDM,975,RC,25515,HCPCS,OUTPATIENT,,,2078,1246.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1038.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,638.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7548.94,9200,
25530 CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,5560103,CDM,975,RC,25530,HCPCS,OUTPATIENT,,,730,438,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,390.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,233.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7549.94,9201,
25565 CLOSED TX RADIALULNAR SHAFT FRACTURES W/MANJ,5560104,CDM,975,RC,25565,HCPCS,OUTPATIENT,,,1440,864,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,783.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,447.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7550.94,9202,
25575 OPTX RADIAL andULNAR SHAFT FX W/FIXJ RADIUS andULNA,5560105,CDM,975,RC,25575,HCPCS,OUTPATIENT,,,2798,1678.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1405.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,858.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7551.94,9203,
25645 Treat wrist bone fracture,5560106,CDM,975,RC,25645,HCPCS,OUTPATIENT,,,1768,1060.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,881.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,544.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7552.94,9204,
27130 Total hip arthroplasty,5560107,CDM,975,RC,27130,HCPCS,OUTPATIENT,,,4229,2537.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2137.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1216.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7553.94,9205,
27235 PRQ SKEL FIXJ FEMORAL FX PROX END NECK,5560108,CDM,975,RC,27235,HCPCS,OUTPATIENT,,,2830,1698,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1427.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,860.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7554.94,9206,
27236 OPTX FEM FX PROX END NCK INT FIXJ/PROSTC RPLCMT,5560109,CDM,975,RC,27236,HCPCS,OUTPATIENT,,,3725,2235,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1880.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1130.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7555.94,9207,
27427 Reconstruction knee,5560110,CDM,975,RC,27427,HCPCS,OUTPATIENT,,,2200,1320,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1109.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,673.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7556.94,9208,
27447 Total knee arthroplasty,5560111,CDM,975,RC,27447,HCPCS,OUTPATIENT,,,4225,2535,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2136.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1215.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7557.94,9209,
27610 Explore/treat ankle joint,5560112,CDM,975,RC,27610,HCPCS,OUTPATIENT,,,2018,1210.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1014.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,612.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7558.94,9210,
27792 OPEN TX DISTAL FIBULAR FRACTURE,5560113,CDM,975,RC,27792,HCPCS,OUTPATIENT,,,2020,1212,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1009.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,612.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7559.94,9211,
27814 OPEN TX BIMALLEOLAR ANKLE FRACTURE,5560114,CDM,975,RC,27814,HCPCS,OUTPATIENT,,,2395,1437,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1199.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,725.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7560.94,9212,
27829 Treat lower leg joint,5560115,CDM,975,RC,27829,HCPCS,OUTPATIENT,,,2150,1290,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1074.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,667.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7561.94,9213,
28306 Incision of metatarsal,5560116,CDM,975,RC,28306,HCPCS,OUTPATIENT,,,1255,753,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,926.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7562.94,9214,
29880 ARTHRS KNEE W/MENISCECTOMY MEDLAT W/SHAVING,5560117,CDM,975,RC,29880,HCPCS,OUTPATIENT,,,1750,1050,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,872.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,533.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7563.94,9215,
29881 ARTHRS KNEE W/MENISCECTOMY MED/LAT W/SHVG,5560118,CDM,975,RC,29881,HCPCS,OUTPATIENT,,,1685,1011,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,839.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,513.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7564.94,9216,
29875 ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX,5560119,CDM,975,RC,29875,HCPCS,OUTPATIENT,,,1540,924,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,769.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,471.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7565.94,9217,
29888 ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ,5560120,CDM,975,RC,29888,HCPCS,OUTPATIENT,,,3065,1839,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1543.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,923.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7566.94,9218,
29877 ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG,5560121,CDM,975,RC,29877,HCPCS,OUTPATIENT,,,1930,1158,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,967.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,589.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7567.94,9219,
27822 OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP,5560122,CDM,975,RC,27822,HCPCS,OUTPATIENT,,,2665,1599,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1332.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,824.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7568.94,9220,
25607 Treat fx rad extra-articul,5560123,CDM,975,RC,25607,HCPCS,OUTPATIENT,,,2281,1368.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1139.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,703.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7569.94,9221,
29820 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL,5560124,CDM,975,RC,29820,HCPCS,OUTPATIENT,,,1660,996,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,827.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,506.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7570.94,9222,
29824 ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY,5560125,CDM,975,RC,29824,HCPCS,OUTPATIENT,,,2072,1243.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1032.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,642.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7571.94,9223,
29826 ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT RELEASE,5560126,CDM,975,RC,29826,HCPCS,OUTPATIENT,,,550,330,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,280.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,162.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7572.94,9224,
29827 Arthroscop rotator cuff repr,5560127,CDM,975,RC,29827,HCPCS,OUTPATIENT,,,3280,1968,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1646.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1012.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7573.94,9225,
64721 NEUROPLASTY /TRANSPOS MEDIAN NRV CARPAL TUNNE,5560128,CDM,975,RC,64721,HCPCS,OUTPATIENT,,,1325,795,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,708.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,413.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7574.94,9226,
27486 REVJ TOTAL KNEE ARTHRP W/WO ALGRFT,5560129,CDM,975,RC,27486,HCPCS,OUTPATIENT,,,4385,2631,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2213.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1329.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7575.94,9227,
27299 UNLISTED PROCEDURE PELVIS/HIP JOINT,5560130,CDM,975,RC,27299,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7576.94,9228,
25525 OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE,5560131,CDM,975,RC,25525,HCPCS,OUTPATIENT,,,2375,1425,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1226.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,751.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7577.94,9229,
27245 TX INTER/PR/SUBTRCHNTRIC FEM FX IMED IMPLTSCREW,5560132,CDM,975,RC,27245,HCPCS,OUTPATIENT,,,3747,2248.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1936.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1161.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7578.94,9230,
20680 REMOVAL IMPLANT DEEP,5560133,CDM,975,RC,20680,HCPCS,OUTPATIENT,,,1270,762,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,928.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,398,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7579.94,9231,
29876 ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS,5560134,CDM,975,RC,29876,HCPCS,OUTPATIENT,,,1980,1188,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1024.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,620.03,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7580.94,9232,
24685 OPEN TREATMENT ULNAR FRACTURE PROXIMAL END,5560135,CDM,975,RC,24685,HCPCS,OUTPATIENT,,,1960,1176,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1013.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,621.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7581.94,9233,
25101 ARTHRT WRST W/JT EXPL W/WO BX W/WO RMVL LOOSE/FB,5560136,CDM,975,RC,25101,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,621.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7582.94,9234,
25605 CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,5560137,CDM,975,RC,25605,HCPCS,OUTPATIENT,,,1510,906,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,823.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7583.94,9235,
25609 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,5560138,CDM,975,RC,25609,HCPCS,OUTPATIENT,,,3160,1896,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1633.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,997.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7584.94,9236,
26735 OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA,5560139,CDM,975,RC,26735,HCPCS,OUTPATIENT,,,1775,1065,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,917.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,565.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7585.94,9237,
27347 EXCISION LESION MENISCUS/CAPSULE KNEE,5560140,CDM,975,RC,27347,HCPCS,OUTPATIENT,,,1580,948,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,818.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,502.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7586.94,9238,
27405 RPR PRIMARY TORN LIGM/CAPSULE KNEE COLLATERAL,5560141,CDM,975,RC,27405,HCPCS,OUTPATIENT,,,2035,1221,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1051.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,643.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7587.94,9239,
29999 UNLISTED PROCEDURE ARTHROSCOPY,5560142,CDM,975,RC,29999,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7588.94,9240,
64718 Revise ulnar nerve at elbow,5560143,CDM,975,RC,64718,HCPCS,OUTPATIENT,,,1770,1062,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,973.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,570.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7589.94,9241,
24358 Repair elbow w/deb open,5560144,CDM,975,RC,24358,HCPCS,OUTPATIENT,,,1566,939.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,809.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,504.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7590.94,9242,
25000 RELEASE DE QUERVAINS Clinic Charge,5560145,CDM,975,RC,25000,HCPCS,OUTPATIENT,,,996,597.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,514.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,328.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7591.94,9243,
Open treatment of tibial shaft fracture with plate/scr,5560146,CDM,975,RC,27758,HCPCS,OUTPATIENT,,,2700,1620,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1397.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,850.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7592.94,9244,
Open treatment of posterior malleolus fracture,5560147,CDM,975,RC,27769,HCPCS,OUTPATIENT,,,2200,1320,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1140.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,689.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7593.94,9245,
"Decompression Fasciotomy,Leg; Ant And/Or Lat Compartments On",5560148,CDM,975,RC,27892,HCPCS,OUTPATIENT,,,1668,1000.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,861.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,509.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7594.94,9246,
Prep Site Trunk/Arm/Leg 1st 100 Sq Cm,5560149,CDM,975,RC,15002,HCPCS,OUTPATIENT,,,690,414,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,380.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,206.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7595.94,9247,
23410 OPEN REPAIR OF ROTATOR CUFF ACUTE,5560150,CDM,975,RC,23410,HCPCS,OUTPATIENT,,,2068,1240.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1282.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,777.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7596.94,9248,
23412 OPEN REPAIR OF ROTATOR CUFF CHRONIC,5560151,CDM,975,RC,23412,HCPCS,OUTPATIENT,,,2575,1545,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1331.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,808.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7597.94,9249,
26608 PRQ SKELETAL FIXJ METACARPAL FX EACH BONE,5560152,CDM,975,RC,26608,HCPCS,OUTPATIENT,,,1400,840,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,732.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,458.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7598.94,9250,
TENDON SHEATH INCISION FINGER,5560153,CDM,975,RC,26055,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,831.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,276.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7599.94,9251,
TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT,5560154,CDM,975,RC,26060,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,391.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,243.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7600.94,9252,
28039 EXCISION TUMOR SOFT TIS FOOT/TOE SUBQ 1.5 CM/>,5560156,CDM,975,RC,28039,HCPCS,OUTPATIENT,,,1040,624,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,757.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,322.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7601.94,9253,
28104 EXC/CURTG BONE CYST/B9 TUMORTARSAL/METATARSAL,5560158,CDM,975,RC,28104,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,807.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,337.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7602.94,9254,
23472 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER,5560159,CDM,975,RC,23472,HCPCS,OUTPATIENT,,,4400,2640,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2290.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1368.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7603.94,9255,
64790 EXC NEUROFIBROMA/NEUROLEMMOMA MAJOR PRPH NRV,5560160,CDM,975,RC,64790,HCPCS,OUTPATIENT,,,2565,1539,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1411.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,808.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7604.94,9256,
64483 NJX ANES/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL,5560161,CDM,975,RC,64483,HCPCS,OUTPATIENT,,,275,165,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,339.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,105.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7605.94,9257,
64484 NJX ANES/STRD W/IMG TFRML EDRL LMBR/SAC EA LVL,5560162,CDM,975,RC,64484,HCPCS,OUTPATIENT,,,135,81,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7606.94,9258,
27506 OPTX FEM SHFT FX W/INSJ IMED IMPLT W/WO SCREW,5560163,CDM,975,RC,27506,HCPCS,OUTPATIENT,,,2730,1638,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2104.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1267.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7607.94,9259,
27535 OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR,5560164,CDM,975,RC,27535,HCPCS,OUTPATIENT,,,2750,1650,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1415.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,850.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7608.94,9260,
HALLUX RIGIDUS W/CHEILECTOMY 1ST MP JT W/O IMPLT,5560165,CDM,975,RC,28289,HCPCS,OUTPATIENT,,,920,552,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1100.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,438.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7609.94,9261,
28485 OPEN TREATMENT METATARSAL FRACTURE EACH,5560167,CDM,975,RC,28485,HCPCS,OUTPATIENT,,,1645,987,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,838.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,533.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7610.94,9262,
REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES,5560168,CDM,975,RC,20694,HCPCS,OUTPATIENT,,,675,405,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,645.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,323.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7611.94,9263,
20670 REMOVAL IMPLANT SUPERFICIAL SEPARATE PROCEDURE,5560169,CDM,975,RC,20670,HCPCS,OUTPATIENT,,,430,258,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,544.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,135.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7612.94,9264,
27310 ARTHRT KNEE W/EXPL DRG/RMVL FB BCE,5560170,CDM,975,RC,27310,HCPCS,OUTPATIENT,,,1480,888,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1140.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,696.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7613.94,9265,
27244 TX INTER/PR/SUBTRCHNTRIC FEMORAL FX SCREW IMPLT,5560172,CDM,975,RC,27244,HCPCS,OUTPATIENT,,,2510,1506,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1937.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1162.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7614.94,9266,
25535 CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION,5560173,CDM,975,RC,25535,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,746.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,439.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7615.94,9267,
25545 OPEN TX ULNAR SHAFT FRACTURE,5560174,CDM,975,RC,25545,HCPCS,OUTPATIENT,,,1240,744,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,963.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,594.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7616.94,9268,
26951 AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR,5560175,CDM,975,RC,26951,HCPCS,OUTPATIENT,,,1780,1068,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,970.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,653.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7617.94,9269,
25606 PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP,5560176,CDM,975,RC,25606,HCPCS,OUTPATIENT,,,1990,1194,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1026.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,636.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7618.94,9270,
25608 OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG,5560178,CDM,975,RC,25608,HCPCS,OUTPATIENT,,,2490,1494,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1281.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,787.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7619.94,9271,
23120 CLAVICULECTOMY PARTIAL,5560180,CDM,975,RC,23120,HCPCS,OUTPATIENT,,,1750,1050,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,904.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,559.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7620.94,9272,
23630 OPTX GRTER HUMERAL TUBEROSITY FRACTURE,5560181,CDM,975,RC,23630,HCPCS,OUTPATIENT,,,1560,936,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1215.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,741.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7621.94,9273,
29882 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL OR LATERAL,5560182,CDM,975,RC,29882,HCPCS,OUTPATIENT,,,2100,1260,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1090.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,653.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7622.94,9274,
29883 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIALLATERAL,5560183,CDM,975,RC,29883,HCPCS,OUTPATIENT,,,1280,768,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1323.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,799.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7623.94,9275,
29884 ARTHRS KNEE W/LYSIS ADHESIONS W/WO MANJ SPX,5560184,CDM,975,RC,29884,HCPCS,OUTPATIENT,,,1210,726,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,951.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,588.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7624.94,9276,
29823 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE,5560185,CDM,975,RC,29823,HCPCS,OUTPATIENT,,,950,570,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,957.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,563.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7625.94,9277,
29848 NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM,5560186,CDM,975,RC,29848,HCPCS,OUTPATIENT,,,1525,915,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,790.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,487.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7626.94,9278,
29870 ARTHROSCOPY KNEE DIAGNOSTIC W/WO SYNOVIAL BX SPX,5560187,CDM,975,RC,29870,HCPCS,OUTPATIENT,,,1230,738,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,864.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,389.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7627.94,9279,
29874 ARTHRS KNEE RMVL LOOSE/FOREIGN BODY,5560188,CDM,975,RC,29874,HCPCS,OUTPATIENT,,,1029,617.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,834.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,511.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7628.94,9280,
97605 PROF NEG PRESS WND TX DME </=50 CM,5560189,CDM,975,RC,97605,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7629.94,9281,
27134 REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT,5560190,CDM,975,RC,27134,HCPCS,OUTPATIENT,,,2950,1770,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3032.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1802.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7630.94,9282,
27301 ID DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION,5560191,CDM,975,RC,27301,HCPCS,OUTPATIENT,,,1550,930,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1026.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,483.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7631.94,9283,
27303 INCISION DEEP W/OPNG BONE CORTEX FEMUR/KNEE,5560193,CDM,975,RC,27303,HCPCS,OUTPATIENT,,,1245,747,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,997.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,609.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7632.94,9284,
27125 HEMIARTHROPLASTY HIP PARTIAL,5560194,CDM,975,RC,27125,HCPCS,OUTPATIENT,,,3940,2364,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1783.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1072.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7633.94,9285,
27266 CLTX POST HIP ARTHRP DIS,5560196,CDM,975,RC,27266,HCPCS,OUTPATIENT,,,1760,1056,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,906.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,555.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7634.94,9286,
27269 OPTX FEMORAL FX PROXIMAL END HEAD,5560197,CDM,975,RC,27269,HCPCS,OUTPATIENT,,,2510,1506,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1959.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1174.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7635.94,9287,
15738 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR,5560198,CDM,975,RC,15738,HCPCS,OUTPATIENT,,,2570,1542,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1478.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1195.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7636.94,9288,
15852 DRESSING CHANGE UNDER ANESTHESIA,5560199,CDM,975,RC,15852,HCPCS,OUTPATIENT,,,95,57,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7637.94,9289,
13160 SECONDARY CLOSURE SURG WOUND/DEHSN EXTSV/COMPLIC,5560200,CDM,975,RC,13160,HCPCS,OUTPATIENT,,,2367,1420.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,903.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,751.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7638.94,9290,
12020 TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,5560202,CDM,975,RC,12020,HCPCS,OUTPATIENT,,,560,336,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,309.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7639.94,9291,
10140 PROF ID HEMATOMA/FLUID,5560207,CDM,975,RC,10140,HCPCS,OUTPATIENT,,,326,195.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7640.94,9292,
10180 IDCOMPLEXPOWOUNDINFECTION,5560208,CDM,975,RC,10180,HCPCS,OUTPATIENT,,,535,321,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,271.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,167.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7641.94,9293,
11010 DBRDMT W/RMVL FM FX/DISLC SKINSUBQ TISSUE,5560209,CDM,975,RC,11010,HCPCS,OUTPATIENT,,,550,330,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,523.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,259.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7642.94,9294,
26356 RPR/ADVMNT FLXR TDN ZONE 2 W/O FR GRFT EA TENDON,5560210,CDM,975,RC,26356,HCPCS,OUTPATIENT,,,2360,1416,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1220.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,751.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7643.94,9295,
11011 DBRDMTW/RMVLFMFX/DISLCSKNSUBQT/M/FMUSC,5560211,CDM,975,RC,11011,HCPCS,OUTPATIENT,,,930,558,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,581.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,281.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7644.94,9296,
11981 INSERT DRUG IMPLANT DEVICE,5560212,CDM,975,RC,11981,HCPCS,OUTPATIENT,,,134,80.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,155.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,59.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7645.94,9297,
11982 REMOVE DRUG IMPANT DEVICE,5560213,CDM,975,RC,11982,HCPCS,OUTPATIENT,,,157,94.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,172.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7646.94,9298,
20103 EXPL PENETRATING WOUND SPX EXTREMITY,5560214,CDM,975,RC,20103,HCPCS,OUTPATIENT,,,980,588,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,873.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7647.94,9299,
20610 DRAIN/INJ MAJOR JNT/BURSA W/O US,5560215,CDM,975,RC,20610,HCPCS,OUTPATIENT,,,190,114,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,43.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7648.94,9300,
20611 DRAIN/INJ JOINT/BURSA W/ US,5560216,CDM,975,RC,20611,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,56.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7649.94,9301,
20690 APPL UNIPLANE XTRNL FIXATION SYSTEM,5560217,CDM,975,RC,20690,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,937.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,566.51,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7650.94,9302,
20692 APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM,5560219,CDM,975,RC,20692,HCPCS,OUTPATIENT,,,2230,1338,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1750.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1068.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7651.94,9303,
20700 MNL PREPINSJ DP RX DLVR DEV,5560220,CDM,975,RC,20700,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,135.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,80.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7652.94,9304,
20701 RMVL DEEP RX DELIVERY DEVICE,5560221,CDM,975,RC,20701,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7653.94,9305,
20704 MNL PREPINSJ I-ARTIC RX DEV,5560224,CDM,975,RC,20704,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,234.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,141.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7654.94,9306,
20705 RMVL I-ARTIC RX DELIVERY DEV,5560225,CDM,975,RC,20705,HCPCS,OUTPATIENT,,,375,225,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,192.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,117.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7655.94,9307,
27030 ARTHROTOMY HIP W/DRAINAGE,5560230,CDM,975,RC,27030,HCPCS,OUTPATIENT,,,2875,1725,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1472.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,888.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7656.94,9308,
27087 RMVL FOREIGN BODY PELVIS/HIP DEEP,5560231,CDM,975,RC,27087,HCPCS,OUTPATIENT,,,1820,1092,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,962.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,585.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7657.94,9309,
27090 RMVL HIP PROSTH SEPARATE PROCEDURE,5560232,CDM,975,RC,27090,HCPCS,OUTPATIENT,,,1625,975,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1300.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,786.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7658.94,9310,
27091 RMVL HIP PROSTH COMP W/TOT HIP PROSTH MMA,5560233,CDM,975,RC,27091,HCPCS,OUTPATIENT,,,3200,1920,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2519.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1507.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7659.94,9311,
27096 Injection SI joint anes/steroid with imaging,5560236,CDM,975,RC,27096,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,237.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.51,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7660.94,9312,
27138 REVJ TOT HIP ARTHRP FEM ONLY W/WO ALGRFT,5560237,CDM,975,RC,27138,HCPCS,OUTPATIENT,,,2980,1788,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2417.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1441.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7661.94,9313,
27132 CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT,5560238,CDM,975,RC,27132,HCPCS,OUTPATIENT,,,2535,1521,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2644.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1581.03,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7662.94,9314,
27137 REVJ TOT HIP ARTHRP ACTBLR W/WO AGRFT/ALGRFT,5560239,CDM,975,RC,27137,HCPCS,OUTPATIENT,,,2970,1782,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2325.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1387.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7663.94,9315,
27422 RCNSTJ DISLC PATELLA W/XTNSR RELIGNMT/MUSC RL,5560240,CDM,975,RC,27422,HCPCS,OUTPATIENT,,,1130,678,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1159.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,705.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7664.94,9316,
27438 ARTHROPLASTY PATELLA W/PROSTHESIS,5560242,CDM,975,RC,27438,HCPCS,OUTPATIENT,,,1685,1011,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1312.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,798.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7665.94,9317,
27487 REV TOT KNEE ARTHRP W/WO ALGRFT FEM  TIB COMP,5560244,CDM,975,RC,27487,HCPCS,OUTPATIENT,,,3550,2130,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2776.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1658.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7666.94,9318,
27488 RMVL PROSTH TOT KNEE PROSTH MMA W/WO INSJ SPACER,5560245,CDM,975,RC,27488,HCPCS,OUTPATIENT,,,2445,1467,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1887.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1137.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7667.94,9319,
27602 DCMPRN FASCT LEG ANT/LATPST  CMPRT,5560246,CDM,975,RC,27602,HCPCS,OUTPATIENT,,,1480,888,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,771.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,452.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7668.94,9320,
27603 ID LEG/ANKLE ABSCESS/HEMATOMA,5560247,CDM,975,RC,27603,HCPCS,OUTPATIENT,,,780,468,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,805.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,368.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7669.94,9321,
25248 EXP W/REMOVAL DEEP FB FOREARM OR WRIST,5560248,CDM,975,RC,25248,HCPCS,OUTPATIENT,,,1250,750,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,640.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,404.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7670.94,9322,
25651 PRQ SKELETAL FIXATION ULNAR STYLOID FRACTURE,5560249,CDM,975,RC,25651,HCPCS,OUTPATIENT,,,965,579,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,745.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,467.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7671.94,9323,
25810 ARTHRODESIS WRIST W/ILIAC/OTHER AUTOGRAFT,5560250,CDM,975,RC,25810,HCPCS,OUTPATIENT,,,2600,1560,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1349.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,823.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7672.94,9324,
26111 EX TUM/VASC MALF SFT TISS HAND/FNGR SUBQ 1.5CM/>,5560253,CDM,975,RC,26111,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,645.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,395.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7673.94,9325,
26160 EXC LES TDN SHTH/JT CAPSL HAND/FNGR,5560255,CDM,975,RC,26160,HCPCS,OUTPATIENT,,,930,558,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,859.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7674.94,9326,
26746 OPTX ARTICULAR FRACTURE MCP/IP JOINT EA,5560256,CDM,975,RC,26746,HCPCS,OUTPATIENT,,,1475,885,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1150.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,704.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7675.94,9327,
26776 PRQ SKEL FIXJ IPHAL JT DISLC W/MANJ,5560257,CDM,975,RC,26776,HCPCS,OUTPATIENT,,,885,531,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,677.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,428.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7676.94,9328,
26860 ARTHRODESIS INTERPHALANGEAL JT W/WO INT FIXJ,5560258,CDM,975,RC,26860,HCPCS,OUTPATIENT,,,1120,672,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,834.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,568.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7677.94,9329,
26605 CLTX METACARPAL FX W/MANIP EACH BONE,5560259,CDM,975,RC,26605,HCPCS,OUTPATIENT,,,580,348,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,486.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,285.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7678.94,9330,
26990 ID PELVIS/HIP JT AREA DEEP ABSCESS/HEMATOMA,5560260,CDM,975,RC,26990,HCPCS,OUTPATIENT,,,1965,1179,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,987.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,640.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7679.94,9331,
26426 RPR XTNSR TDN CNTRL SLIP TISS W/LAT BAND EA FNGR,5560261,CDM,975,RC,26426,HCPCS,OUTPATIENT,,,1000,600,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,773.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,480.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7680.94,9332,
26785 OPEN TX INTERPHALANGEAL JOINT DISLOCATION,5560262,CDM,975,RC,26785,HCPCS,OUTPATIENT,,,1080,648,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,841.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,520.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7681.94,9333,
26841 ARTHRD CARPO/METACARPAL JT THUMB W/WO INT FIXJ,5560263,CDM,975,RC,26841,HCPCS,OUTPATIENT,,,1500,900,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1084.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,723.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7682.94,9334,
27540 OPEN TX INTERCONDYLAR SPINE/TUBRST FX KNEE,5560264,CDM,975,RC,27540,HCPCS,OUTPATIENT,,,1630,978,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1271.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,772.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7683.94,9335,
27509 PRQ FIX SUPRA/TRANS/INTERCONDYLAR FEMUR FX,5560265,CDM,975,RC,27509,HCPCS,OUTPATIENT,,,1987,1192.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1001.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,638.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7684.94,9336,
27524 OPTX PATLLR FX W/INT FIXJ/PATLLCSOFT TISS RPR,5560266,CDM,975,RC,27524,HCPCS,OUTPATIENT,,,1525,915,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1174.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,715.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7685.94,9337,
27592 AMP THIGH THRU FEMUR OPEN CIRCULAR,5560267,CDM,975,RC,27592,HCPCS,OUTPATIENT,,,2108,1264.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1085.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,636.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7686.94,9338,
27594 AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION,5560269,CDM,975,RC,27594,HCPCS,OUTPATIENT,,,1568,940.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,798.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,477.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7687.94,9339,
27756 PRQ SKELETAL FIXATION TIBIAL SHAFT FRACTURE,5560270,CDM,975,RC,27756,HCPCS,OUTPATIENT,,,1730,1038,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,894.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,549.37,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7688.94,9340,
27759 TX TIBL SHFT FX IMED IMPLT W/WO SCREWS/CERCLA,5560273,CDM,975,RC,27759,HCPCS,OUTPATIENT,,,2004,1202.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1569.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,945.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7689.94,9341,
27766 OP TX MEDIAL ANKLE FX,5560276,CDM,975,RC,27766,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,940.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7690.94,9342,
27788 CLTX DSTL FIBULAR FX LAT MALLS W/MANIPULATION,5560280,CDM,975,RC,27788,HCPCS,OUTPATIENT,,,830,498,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,642.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,370.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7691.94,9343,
27818 CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION,5560288,CDM,975,RC,27818,HCPCS,OUTPATIENT,,,1310,786,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,741.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,424.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7692.94,9344,
27823 OPTX TRIMALLEOLAR ANKLE FX W/FIXJ PST LIP,5560289,CDM,975,RC,27823,HCPCS,OUTPATIENT,,,1965,1179,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1515.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,930.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7693.94,9345,
27842 CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIXJ,5560290,CDM,975,RC,27842,HCPCS,OUTPATIENT,,,1485,891,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,758.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,470.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7694.94,9346,
27848 OPTX ANKLE DISLC W/WO PRQ SKEL FIX W/WO INT/EXT FIX,5560292,CDM,975,RC,27848,HCPCS,OUTPATIENT,,,2430,1458,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1249.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,750.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7695.94,9347,
28292 CORRECTION HALLUX VALGUS; W/SESMDC W/RESCJ PROXPHAL,5560293,CDM,975,RC,28292,HCPCS,OUTPATIENT,,,1450,870,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1117.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7696.94,9348,
28406 PRQ SKELETAL FIX CALCANEAL FX W/MANIPULATION,5560294,CDM,975,RC,28406,HCPCS,OUTPATIENT,,,1615,969,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,813.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,558.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7697.94,9349,
28805 AMPUTATION FOOT TRANSMETARSAL,5560295,CDM,975,RC,28805,HCPCS,OUTPATIENT,,,2215,1329,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1146.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,673.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7698.94,9350,
28825 AMPUTATION TOE INTERPHALANGEAL JOINT,5560298,CDM,975,RC,28825,HCPCS,OUTPATIENT,,,355,213,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,812.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7699.94,9351,
28496 PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MANJ,5560299,CDM,975,RC,28496,HCPCS,OUTPATIENT,,,475,285,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,679.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,257.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7700.94,9352,
28476 PRQ SKEL FIXJ METAR FX W/MANJ,5560300,CDM,975,RC,28476,HCPCS,OUTPATIENT,,,750,450,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,533.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,362.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7701.94,9353,
26210 EXC/CURETTAGE CYST/TUMOR PHALANX FINGER,5560301,CDM,975,RC,26210,HCPCS,OUTPATIENT,,,875,525,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,681.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,426.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7702.94,9354,
26615 OPEN TX METACARPAL FX SINGLE EA BONE,5560305,CDM,975,RC,26615,HCPCS,OUTPATIENT,,,1140,684,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,886,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,547.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7703.94,9355,
26675 CLTX CARPO/MTCRPL DISLC NO THUMB W/MANJ W/ANES,5560310,CDM,975,RC,26675,HCPCS,OUTPATIENT,,,815,489,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,697.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,405.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7704.94,9356,
26725 CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA,5560318,CDM,975,RC,26725,HCPCS,OUTPATIENT,,,605,363,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,510.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,294.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7705.94,9357,
26727 PRQ SKEL FIX PHLNGL SHFT FX PROX/MIDDLE PX/F/T,5560319,CDM,975,RC,26727,HCPCS,OUTPATIENT,,,815,489,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,721.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,452.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7706.94,9358,
20240 BIOPSY BONE OPEN SUPERFICIAL,5560324,CDM,975,RC,20240,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,236.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,133.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7707.94,9359,
20245 BIOPSY BONE OPEN DEEP,5560325,CDM,975,RC,20245,HCPCS,OUTPATIENT,,,705,423,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,557.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,326,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7708.94,9360,
23415 CORACOACROMIAL LIG REL W/WO ACROMIOPLASTY,5560345,CDM,975,RC,23415,HCPCS,OUTPATIENT,,,1310,786,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1087.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,662.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7709.94,9361,
23515 ORIF OF CLAVICULAR FRACTURE,5560350,CDM,975,RC,23515,HCPCS,OUTPATIENT,,,2180,1308,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1119.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,684.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7710.94,9362,
23700 MANJ W/ANES SHOULDER JOINT W/FIX APPARATUS,5560370,CDM,975,RC,23700,HCPCS,OUTPATIENT,,,390,234,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,304.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,185.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7711.94,9363,
24105 EXCISION OLECRANON BURSA,5560405,CDM,975,RC,24105,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,538.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,342.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7712.94,9364,
24342 RINSJ RPTD BICEPS/TRICEPS TDN DSTL W/WO TDN GRF,5560410,CDM,975,RC,24342,HCPCS,OUTPATIENT,,,1550,930,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1211.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,735.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7713.94,9365,
24343 REPAIR LATERAL COLLATERAL LIGAMENT ELBOW,5560411,CDM,975,RC,24343,HCPCS,OUTPATIENT,,,1420,852,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1099.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,678.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7714.94,9366,
24515 OPTX HUMERAL SHFT FX W/PLATE/SCREWS W/WOCERCLAGE,5560415,CDM,975,RC,24515,HCPCS,OUTPATIENT,,,1760,1056,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1369.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,835.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7715.94,9367,
24516 TX HUMERAL SHFT FX W/INSJ IMED IMPLT W/W CERCLGE,5560416,CDM,975,RC,24516,HCPCS,OUTPATIENT,,,1725,1035,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1346.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,815.51,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7716.94,9368,
24546 OP TX HUMERAL SUPRA/INTERCONDYLAR FX W/WO INT/EXT FIX,5560420,CDM,975,RC,24546,HCPCS,OUTPATIENT,,,3160,1896,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1628.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,983.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7717.94,9369,
24582 PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MANJ,5560430,CDM,975,RC,24582,HCPCS,OUTPATIENT,,,1620,972,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1256.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,774.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7718.94,9370,
24605 CLTX ELBOW DISLOCATION W/ANES,5560435,CDM,975,RC,24605,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,728.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,456.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7719.94,9371,
24615 OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION,5560438,CDM,975,RC,24615,HCPCS,OUTPATIENT,,,1430,858,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1112.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,678.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7720.94,9372,
"24666 OPEN RX RADIAL HEAD FX, PROSTH IMPANT",5560450,CDM,975,RC,24666,HCPCS,OUTPATIENT,,,2200,1320,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1139.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,695.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7721.94,9373,
25020 DCMPRN FASCT F/ARMWRST FLXR/XTNSR W/O DBRDMT,5560452,CDM,975,RC,25020,HCPCS,OUTPATIENT,,,1375,825,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,872.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,683.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7722.94,9374,
25035 INCISION DEEP BONE CORTEX FOREARM and/WRIST,5560455,CDM,975,RC,25035,HCPCS,OUTPATIENT,,,1145,687,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,906.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,561.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7723.94,9375,
25028 I andD FOREARM and/WRIST DEEP ABSCESS/HEMATOMA,5560456,CDM,975,RC,25028,HCPCS,OUTPATIENT,,,1300,780,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,802.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,638.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7724.94,9376,
25031 I andD FOREARM and/WRIST BURSA,5560457,CDM,975,RC,25031,HCPCS,OUTPATIENT,,,850,510,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,535.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,351.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7725.94,9377,
25040 ARTHRT RDCRPL/MIDCARPL JT W/EXPL DRG/RMVL FB,5560458,CDM,975,RC,25040,HCPCS,OUTPATIENT,,,1100,660,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,870.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,532.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7726.94,9378,
25574 OPTX RADIAL andULNAR SHFT FX W/FIXJ RADIUS/ULNA,5560460,CDM,975,RC,25574,HCPCS,OUTPATIENT,,,1320,792,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1046.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,642.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7727.94,9379,
25628 OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE,5560468,CDM,975,RC,25628,HCPCS,OUTPATIENT,,,1445,867,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1117.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,683.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7728.94,9380,
27620 ARTHRT ANKLE W/EXPL W/WO BX W/WO RMVL LOOSE/FB,5560469,CDM,975,RC,27620,HCPCS,OUTPATIENT,,,890,534,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,699.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,425.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7729.94,9381,
27650 RPR PRIMARY OP/PRQ RUPTD ACHILLES TENDON,5560470,CDM,975,RC,27650,HCPCS,OUTPATIENT,,,1320,792,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1018.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,623.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7730.94,9382,
27635 EXC/CURETTAGE BONE CYST/TUMOR TIBIA/FIBULA,5560471,CDM,975,RC,27635,HCPCS,OUTPATIENT,,,1090,654,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,902.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,550.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7731.94,9383,
27825 CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRAC,5560475,CDM,975,RC,27825,HCPCS,OUTPATIENT,,,1050,630,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,841.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,472.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7732.94,9384,
27827 OPEN TX PILON FX INT FIX OF TIBIA ONLY,5560477,CDM,975,RC,27827,HCPCS,OUTPATIENT,,,2235,1341,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1716.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1056.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7733.94,9385,
27828 OPEN TX PILON FX INT FIX OF TIBIA AND FIBULA,5560478,CDM,975,RC,27828,HCPCS,OUTPATIENT,,,2650,1590,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2055.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1253.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7734.94,9386,
"27880 AMPUTATION LEG, THROUGH TIBIA AND FIBULA",5560480,CDM,975,RC,27880,HCPCS,OUTPATIENT,,,2850,1710,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1459.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,853.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7735.94,9387,
62323 NJX INTERLAMINAR LMBR/SAC,5560523,CDM,975,RC,62323,HCPCS,OUTPATIENT,,,320,192,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,390.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,94.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7736.94,9388,
27536 OPTX TIBIAL FX PROX BICONDYLAR W/WO INT FIXJ,5560550,CDM,975,RC,27536,HCPCS,OUTPATIENT,,,2320,1392,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1869.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1125.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7737.94,9389,
27556 OPTX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR,5560556,CDM,975,RC,27556,HCPCS,OUTPATIENT,,,1770,1062,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1379.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,830.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7738.94,9390,
27507 OPTX FEM SHFT FX W/PLATE/SCREWS W/WO CERCLAGE,5560558,CDM,975,RC,27507,HCPCS,OUTPATIENT,,,1895,1137,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1530.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,917.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7739.94,9391,
27511 OPTX FEMORAL SUPRACONDYLAR FX W/O XTN,5560561,CDM,975,RC,27511,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1572.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,944.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7740.94,9392,
27580 ARTHRODESIS KNEE ANY TECHNIQUE,5560580,CDM,975,RC,27580,HCPCS,OUTPATIENT,,,2965,1779,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2265.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1395.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7741.94,9393,
27176 TX SLP FEM EPIPHYSIS SNGL/MULTI PINNING SITU,5560596,CDM,975,RC,27176,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1433.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,874.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7742.94,9394,
27372 REMOVALFOREIGNBODYTHIGH,5560622,CDM,975,RC,27372,HCPCS,OUTPATIENT,,,785,471,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,896.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,379.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7743.94,9395,
27380 SUTURE INFRAPATELLAR TENDON PRIMARY,5560680,CDM,975,RC,27380,HCPCS,OUTPATIENT,,,1211,726.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,923.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,588.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7744.94,9396,
97607 PROF NEG PRESS WND TX NON DME </=50 SQ CM,5560707,CDM,975,RC,97607,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7745.94,9397,
28322 RPR NON/MALUNION METARSAL W/WO BONE GRAFT,5560722,CDM,975,RC,28322,HCPCS,OUTPATIENT,,,1125,675,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1199.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,549.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7746.94,9398,
28525 OPTX FX PHLX/PHLG OTH/THN GRT TOE,5560789,CDM,975,RC,28525,HCPCS,OUTPATIENT,,,780,468,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,861.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,386.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7747.94,9399,
26011 DRAIN FINGER ABSCESS COMPLICATED,5560811,CDM,975,RC,26011,HCPCS,OUTPATIENT,,,529,317.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,590.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,174.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7748.94,9400,
26020 DRAIN TENDON SHEATH DIGIT and/PALM EACH,5560820,CDM,975,RC,26020,HCPCS,OUTPATIENT,,,1081,648.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,666.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,527.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7749.94,9401,
26045 FASCIOTOMY PALMAR OPEN PARTIAL,5560827,CDM,975,RC,26045,HCPCS,OUTPATIENT,,,950,570,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,723.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,449.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7750.94,9402,
29871 ARTHROSCOPY KNEE INFECTION LAVAGE  and DRAINAGE,5560931,CDM,975,RC,29871,HCPCS,OUTPATIENT,,,985,591,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,799.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,489.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7751.94,9403,
Report,6175491,CDM,972,RC,70549,HCPCS,OUTPATIENT,,,270,162,26,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,530.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,238.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7752.94,9404,
MRA Neck w/ + w/o Contrast,6175491,CDM,610,RC,70549,HCPCS,OUTPATIENT,,,2000,1200,26,1700,85,,1360,Percent of total billed charges,85% of total billed charges,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,1579.22,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,703,35.15,,,fee schedule,35.15% of LA custom fee schedule,639,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,900,100,,,case rate,pays based on per visit rate,639,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7753.94,9405,
93000 Electrocardiogram complete,7325730,CDM,730,RC,93000,HCPCS,OUTPATIENT,,,70,42,,59.5,85,,47.6,Percent of total billed charges,85% of total billed charges,164.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,164.11,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,24.61,35.15,,,fee schedule,35.15% of LA custom fee schedule,22.37,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,60,100,,,case rate,pays based on per visit rate,22.37,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7754.94,9406,
EKG (Resp),7325749,CDM,730,RC,93005,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.91,35.15,,,fee schedule,35.15% of LA custom fee schedule,33.55,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,60,100,,,case rate,pays based on per visit rate,33.55,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7755.94,9407,
93005 EKG CHARGE,7325749,CDM,730,RC,93005,HCPCS,OUTPATIENT,,,105,63,,89.25,85,,71.4,Percent of total billed charges,85% of total billed charges,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,75.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,36.91,35.15,,,fee schedule,35.15% of LA custom fee schedule,33.55,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,60,100,,,case rate,pays based on per visit rate,33.55,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7756.94,9408,
REMOTE 30 DAY ECG REV/REPORT,7325755,CDM,985,RC,93228,HCPCS,OUTPATIENT,,,78,46.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7757.94,9409,
TELEMETRY PROFESSIONAL FEE,7325755,CDM,985,RC,93228,HCPCS,OUTPATIENT,,,78,46.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7758.94,9410,
93225 HOLTER MONITOR CHARGE,7332257,CDM,731,RC,93225,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,205.8,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,205.8,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.09,35.15,,63.272,percent of total billed charges,35.15% of total billed charges,6.71,31.95,,5.368,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,100,,,case rate,pays based on per visit rate,71.89,31.95,,57.512,percent of total billed charges,31.95% of total billed charges,7759.94,9411,
93227 HOLTER MONITOR INTERPRETATION CHARGE,7332273,CDM,985,RC,93227,HCPCS,OUTPATIENT,,,118,70.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,17.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7760.94,9412,
93010 EKG INTERPRETATION  REPORT CHARGE,7340748,CDM,985,RC,93010,HCPCS,OUTPATIENT,,,40,24,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,15.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7761.94,9413,
EKG Interp Only,7340748,CDM,985,RC,93010,HCPCS,OUTPATIENT,,,40,24,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,15.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7762.94,9414,
93270 EVENT RECORDING CHARGE,7343494,CDM,731,RC,93270,HCPCS,OUTPATIENT,,,225,135,,191.25,85,,153,Percent of total billed charges,85% of total billed charges,205.8,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,205.8,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,79.09,35.15,,63.272,percent of total billed charges,35.15% of total billed charges,4.47,31.95,,3.576,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,95,100,,,case rate,pays based on per visit rate,71.89,31.95,,57.512,percent of total billed charges,31.95% of total billed charges,7763.94,9415,
93272 EVENT MONITORING INTERPRETATION CHARGE,7343502,CDM,987,RC,93272,HCPCS,OUTPATIENT,,,118,70.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,22.91,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7764.94,9416,
55250 VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS,9200007,CDM,982,RC,55250,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,627.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,217.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7765.94,9417,
52007 CYSTOURETHROSCOPY,9200015,CDM,521,RC,52007,HCPCS,OUTPATIENT,,,488,292.8,,414.8,85,,331.84,Percent of total billed charges,85% of total billed charges,4651.49,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4651.49,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,155.92,31.95,,124.736,percent of total billed charges,31.95% of total billed charges,155.92,31.95,,124.736,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,185.44,38,,148.352,percent of total billed charges,38% of total billed charges,195.2,40,,156.16,percent of total billed charges,40% of total billed charges,7766.94,9418,
52007 CYSTOSCOPY AND BIOPSY,9200015,CDM,982,RC,52007,HCPCS,OUTPATIENT,,,488,292.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,743.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,156.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7767.94,9419,
52648 LASER VAPOR PROSTATE COMPLET,9200016,CDM,982,RC,52648,HCPCS,OUTPATIENT,,,2805,1683,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2704.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,658.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7768.94,9420,
52204 CYSTO W BIOPSY,9200017,CDM,982,RC,52204,HCPCS,OUTPATIENT,,,1379,827.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,610.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,133.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7769.94,9421,
52344 CYSTO W URETRSC BALLOON DIL,9200018,CDM,982,RC,52344,HCPCS,OUTPATIENT,,,1521,912.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,644.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,348.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7770.94,9422,
52320 CYSTO W REMOVAL URETE CALCU,9200019,CDM,982,RC,52320,HCPCS,OUTPATIENT,,,1015,609,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,429.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,232.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7771.94,9423,
52214 CYSTO W FULGURATION,9200020,CDM,982,RC,52214,HCPCS,OUTPATIENT,,,725,435,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1118.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7772.94,9424,
52276 CYSTO W DV INTERN URETHROTOM,9200021,CDM,982,RC,52276,HCPCS,OUTPATIENT,,,1090,654,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,460.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,249.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7773.94,9425,
52315 CYSTO W/COMPLEX REMOVAL STONE  STENT,9200022,CDM,982,RC,52315,HCPCS,OUTPATIENT,,,856,513.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,732.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,258.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7774.94,9426,
DRAINAGE SCROTAL WALL ABSCESS,9200023,CDM,521,RC,55100,HCPCS,OUTPATIENT,,,510,306,,433.5,85,,346.8,Percent of total billed charges,85% of total billed charges,4079.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4079.44,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,162.95,31.95,,130.36,percent of total billed charges,31.95% of total billed charges,162.95,31.95,,130.36,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,193.8,38,,155.04,percent of total billed charges,38% of total billed charges,204,40,,163.2,percent of total billed charges,40% of total billed charges,7775.94,9427,
52275 CYSTO W INTERNAL URETHRO MAL,9200024,CDM,982,RC,52275,HCPCS,OUTPATIENT,,,1025,615,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,828.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,234.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7776.94,9428,
54840 EXC SPERMATOCELE W/WO EPIDID,9200025,CDM,982,RC,54840,HCPCS,OUTPATIENT,,,1315,789,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,568.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,306.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7777.94,9429,
54830 EXC LESION/CYST EPIDIDYMI,9200026,CDM,982,RC,54830,HCPCS,OUTPATIENT,,,1526,915.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,659.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,354.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7778.94,9430,
52601 TRANSURETHRAL ELEC RESEC PRO,9200027,CDM,982,RC,52601,HCPCS,OUTPATIENT,,,3470,2082,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1264.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,691.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7779.94,9431,
52260 CYSTO W DILATION BLADDER ANE,9200028,CDM,982,RC,52260,HCPCS,OUTPATIENT,,,869,521.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,365.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,198.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7780.94,9432,
52240 CYSTO W FULG/RESEC BLAD TUMO,9200029,CDM,982,RC,52240,HCPCS,OUTPATIENT,,,1615,969,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,683.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,369.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7781.94,9433,
55705 BIOPSY OF PROSTATE,9200030,CDM,982,RC,55705,HCPCS,OUTPATIENT,,,810,486,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,472.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,251.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7782.94,9434,
"Reduction of torsion of testis, surgical",9200031,CDM,521,RC,52332,HCPCS,OUTPATIENT,,,635,381,,539.75,85,,431.8,Percent of total billed charges,85% of total billed charges,5842.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,5842.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,202.88,31.95,,162.304,percent of total billed charges,31.95% of total billed charges,202.88,31.95,,162.304,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,241.3,38,,193.04,percent of total billed charges,38% of total billed charges,254,40,,203.2,percent of total billed charges,40% of total billed charges,7783.94,9435,
52332 CYSTO W INSERT INDWELL STEN,9200031,CDM,982,RC,52332,HCPCS,OUTPATIENT,,,635,381,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,760.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7784.94,9436,
52234 CYSTO W/REMOVAL TUMOR SMAL,9200032,CDM,982,RC,52234,HCPCS,OUTPATIENT,,,1013,607.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,428.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,231.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7785.94,9437,
52341 CYSTO W TX URET STRIC DILAT,9200033,CDM,982,RC,52341,HCPCS,OUTPATIENT,,,1170,702,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,494.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,267.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7786.94,9438,
52317 LITHOLAPAXY REM CALCULUS 2.5,9200035,CDM,982,RC,52317,HCPCS,OUTPATIENT,,,1435,861,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1370.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,326.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7787.94,9439,
52235 CYSTO W FULG BLADDER TU 2-5C,9200036,CDM,982,RC,52235,HCPCS,OUTPATIENT,,,1189,713.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,502.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,272.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7788.94,9440,
52351 CYSTO W URETERSCOPE/PYELO,9200037,CDM,982,RC,52351,HCPCS,OUTPATIENT,,,1248,748.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,527.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,285.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7789.94,9441,
52500 TRANSURETHRAL RESECTION BLDN,9200038,CDM,982,RC,52500,HCPCS,OUTPATIENT,,,2010,1206,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,841.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,468.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7790.94,9442,
49329 LAPARO PROC ABDM/PER/OMENT,9200039,CDM,960,RC,49329,HCPCS,OUTPATIENT,,,1100,660,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7791.94,9443,
26116  EXC HAND TUM DEEP < 1.5 CM,9200040,CDM,960,RC,26116,HCPCS,OUTPATIENT,,,1638,982.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,813.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,499.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7792.94,9444,
45309  PROCTOSGMDSC RIGID RMVL 1 LESION SNARE TQ,9200041,CDM,960,RC,45309,HCPCS,OUTPATIENT,,,280,168,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,267.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,84.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7793.94,9445,
43202 ESOPHAGOSCOPY FLEX BIOPSY,9200042,CDM,960,RC,43202,HCPCS,OUTPATIENT,,,326,195.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,469.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,96.91,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7794.94,9446,
"51040 CYSTOSTOMY,CYSTOTOMY W DRAI",9200043,CDM,982,RC,51040,HCPCS,OUTPATIENT,,,1189,713.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,494.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,276.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7795.94,9447,
53620 DILATION URETHR STRIC FIL,9200044,CDM,982,RC,53620,HCPCS,OUTPATIENT,,,455,273,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,220.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,82.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7796.94,9448,
54860 EPIDIDYMECTOMY; UNILATERA,9200046,CDM,982,RC,54860,HCPCS,OUTPATIENT,,,1725,1035,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,742.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,398.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7797.94,9449,
52001 CYSTO W IRR EVAC CLOT,9200047,CDM,982,RC,52001,HCPCS,OUTPATIENT,,,1190,714,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,664.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,270.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7798.94,9450,
52356 CYSTO W URET/PYE/LITHO/STEN,9200049,CDM,982,RC,52356,HCPCS,OUTPATIENT,,,1695,1017,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,727.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,392.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7799.94,9451,
50590 LITHOTRIPSY ESL,9200056,CDM,982,RC,50590,HCPCS,OUTPATIENT,,,2306,1383.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1229.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,543.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7800.94,9452,
52354 CYSTO W URETER/PYELOSCOP BIO,9200064,CDM,982,RC,52354,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,728.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,393.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7801.94,9453,
52318 LITHOLAPAXY COMPL >2.5C,9200072,CDM,982,RC,52318,HCPCS,OUTPATIENT,,,1929,1157.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,828.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,446.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7802.94,9454,
22901 EXC TUM SFT TISSUE ABDL WALL SUBFASC 5CM/>,9200079,CDM,960,RC,22901,HCPCS,OUTPATIENT,,,1705,1023,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1055.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,634.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7803.94,9455,
22902 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM,9200080,CDM,960,RC,22902,HCPCS,OUTPATIENT,,,1028,616.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,682.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,317.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7804.94,9456,
49440 PLACE GASTROSTOMY TUBE PERC,9200081,CDM,960,RC,49440,HCPCS,OUTPATIENT,,,646,387.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1368.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,190.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7805.94,9457,
46611  ANOSCOPY,9200082,CDM,960,RC,46611,HCPCS,OUTPATIENT,,,340,204,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,280.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7806.94,9458,
46606 ANOSCOPY AND BIOPSY,9200083,CDM,960,RC,46606,HCPCS,OUTPATIENT,,,317,190.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,352.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7807.94,9459,
15940 EXC ISCHIAL PRESSURE ULCER W/PRIMARY SUTURE,9200090,CDM,960,RC,15940,HCPCS,OUTPATIENT,,,2100,1260,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,794.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,670.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7808.94,9460,
52352 CYSTO W URETER/PYELO W REMOV,9200098,CDM,982,RC,52352,HCPCS,OUTPATIENT,,,1445,867,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,618.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,333.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7809.94,9461,
52005 CYSTO W URETERAL CATH/PYEGRA,9200106,CDM,982,RC,52005,HCPCS,OUTPATIENT,,,545,327,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,459.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7810.94,9462,
55040 PF EXCISION HYDROCELE UNILATERAL,9200108,CDM,982,RC,55040,HCPCS,OUTPATIENT,,,970,582,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,597.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,322.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7811.94,9463,
55500 EXC HYDROCELE SPRMATIC CORD UNI SPX,9200110,CDM,960,RC,55500,HCPCS,OUTPATIENT,,,1170,702,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,701.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,372.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7812.94,9464,
51610 INJ RETROGRADE URETHROCYSTOG,9200155,CDM,982,RC,51610,HCPCS,OUTPATIENT,,,265,159,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,183.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7813.94,9465,
43250 EGD CAUTERY TUMOR POLYP,9200160,CDM,960,RC,43250,HCPCS,OUTPATIENT,,,540,324,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,611.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,159.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7814.94,9466,
44640 REPAIR BOWEL - SKIN FISTULA,9200162,CDM,960,RC,44640,HCPCS,OUTPATIENT,,,4379,2627.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2258.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1325.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7815.94,9467,
46020 PLACEMENT OF SETON,9200165,CDM,960,RC,46020,HCPCS,OUTPATIENT,,,731,438.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,425.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,110.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7816.94,9468,
47610 CHOLECYSTECTOMY W/EXPLOR COMMON DUCT,9200166,CDM,960,RC,47610,HCPCS,OUTPATIENT,,,3200,1920,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2021.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1189.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7817.94,9469,
27339  EXC THIGH/KNEE TUM DEP 5CM/>,9200167,CDM,960,RC,27339,HCPCS,OUTPATIENT,,,2345,1407,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1188.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,718.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7818.94,9470,
27045 EXC HIP/PELV TUM DEEP 5 CM/>.,9200170,CDM,960,RC,27045,HCPCS,OUTPATIENT,,,2230,1338,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1169.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,697.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7819.94,9471,
Bladder Scan,9400110,CDM,402,RC,51798,HCPCS,OUTPATIENT,,,305,183,,259.25,85,,207.4,Percent of total billed charges,85% of total billed charges,153.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,107.21,35.15,,,fee schedule,35.15% of LA custom fee schedule,97.45,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,,case rate,pays based on per visit rate,97.45,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7820.94,9472,
Bladder Scan,9400110,CDM,402,RC,51798,HCPCS,OUTPATIENT,,,305,183,,259.25,85,,207.4,Percent of total billed charges,85% of total billed charges,153.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.63,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,107.21,35.15,,,fee schedule,35.15% of LA custom fee schedule,97.45,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,265,100,,,case rate,pays based on per visit rate,97.45,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,7821.94,9473,
53600 DIL URETH STRICT MALE INITIAL PF,9400111,CDM,982,RC,53600,HCPCS,OUTPATIENT,,,247,148.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7822.94,9474,
53601 DIL URETH STRICT MALE SBSQ PF,9400112,CDM,982,RC,53601,HCPCS,OUTPATIENT,,,202,121.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,133.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7823.94,9475,
51701 INSERT BLADDER CATHETER,9400128,CDM,982,RC,51701,HCPCS,OUTPATIENT,,,152,91.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.37,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7824.94,9476,
53660 DIL URETHRA FEMALE INITIAL PF,9400130,CDM,982,RC,53660,HCPCS,OUTPATIENT,,,178,106.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,114.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7825.94,9477,
53661 DIL URETHRA FEMALE SBSQ PF,9400131,CDM,982,RC,53661,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7826.94,9478,
81000 UR,9400201,CDM,982,RC,81000,HCPCS,OUTPATIENT,,,18,10.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,4.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,4.02,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7827.94,9479,
96372 IM/SQ IN,9400219,CDM,982,RC,96372,HCPCS,OUTPATIENT,,,70,42,59,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,19.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,13.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7828.94,9480,
J9217 LEUPROLIDE ACETATE 7.5MG,9400300,CDM,982,RC,J9217,HCPCS,OUTPATIENT,,,688,412.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,185.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,176.51,100,,,fee schedule,100% of CMS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7829.94,9481,
PROSTATE NEEDLE BIOPSY,9400334,CDM,982,RC,55700,HCPCS,OUTPATIENT,,,614,368.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,421.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,123.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7830.94,9482,
REPEAT THYROID SURGERY,9400340,CDM,982,RC,60260,HCPCS,OUTPATIENT,,,3400,2040,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1509.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1036.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7831.94,9483,
Echo guide for biopsy,9400342,CDM,977,RC,76942,HCPCS,OUTPATIENT,,,160,96,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,73.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.94,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7832.94,9484,
EGD CONTROL BLEEDING ANY,9400345,CDM,982,RC,43255,HCPCS,OUTPATIENT,,,650,390,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,960.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,187.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7833.94,9485,
LAPAROSCOPE PROC STOM,9400352,CDM,982,RC,43659,HCPCS,OUTPATIENT,,,1750,1050,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7834.94,9486,
52441 CYSTOURETHRO W/IMPLANT,9400355,CDM,982,RC,52441,HCPCS,OUTPATIENT,,,701,420.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2006.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,197.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7835.94,9487,
52332 CYSTOURETHROSCOPY,9400367,CDM,983,RC,52332,HCPCS,OUTPATIENT,,,635,381,AQ,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,760.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7836.94,9488,
"Irrigation Bladder, Simple Charge",9400383,CDM,982,RC,51700,HCPCS,OUTPATIENT,,,232,139.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,28.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7837.94,9489,
19285 PROF PLACEMENT BREAST LOC DE,9500017,CDM,972,RC,19285,HCPCS,OUTPATIENT,,,360,216,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,503.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,79.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7838.94,9490,
93880 PROF US CAROTID DOPPLER,9525326,CDM,972,RC,93880,HCPCS,OUTPATIENT,,,118,70.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,251.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,118,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7839.94,9491,
93306 PROF US ECHO TTHRC COMPLET,9525409,CDM,972,RC,93306,HCPCS,OUTPATIENT,,,188,112.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,348.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7840.94,9492,
93971 PROF US VENOUS DOPPLER UNILA,9527009,CDM,972,RC,93971,HCPCS,OUTPATIENT,,,68,40.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7841.94,9493,
93970 PROF US VENOUS DOPPLER BILA,9527157,CDM,972,RC,93970,HCPCS,OUTPATIENT,,,105,63,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,243.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,105,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7842.94,9494,
93925 PROF US ARTERIAL DOPPLER B,9527280,CDM,972,RC,93925,HCPCS,OUTPATIENT,,,119,71.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,318.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,119,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7843.94,9495,
93325 PROF US DOP ECHO COLOR FLOW,9528601,CDM,972,RC,93325,HCPCS,OUTPATIENT,,,11,6.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,41.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7844.94,9496,
93926 PROF US ARTERIAL DOPPLER UN,9529139,CDM,972,RC,93926,HCPCS,OUTPATIENT,,,76,45.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,168.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7845.94,9497,
93350 PROF ECHO W/WO MMODE COMP R,9533503,CDM,972,RC,93350,HCPCS,OUTPATIENT,,,212,127.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,317.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7846.94,9498,
G0202 PROF MAMMO SCREEENING BILA,9538113,CDM,972,RC,G0202,HCPCS,OUTPATIENT,,,105,63,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7847.94,9499,
G0204 PROF MAMMO DIAGNOSTIC BILA,9538121,CDM,972,RC,G0204,HCPCS,OUTPATIENT,,,131,78.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7848.94,9500,
G0206 PROF MAMMO DIAGNOSTIC UNILA,9538139,CDM,972,RC,G0206,HCPCS,OUTPATIENT,,,105,63,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7849.94,9501,
19281 PROF MAMMO PERQ DVC BREAST,9538246,CDM,972,RC,19281,HCPCS,OUTPATIENT,,,310,186,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,258.43,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,92.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7850.94,9502,
19282 PROF MAMMO PERQ DVC BREAST,9538253,CDM,972,RC,19282,HCPCS,OUTPATIENT,,,107,64.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7851.94,9503,
93975 PROF US DUPLEX SCAN FLOW COM,9539756,CDM,972,RC,93975,HCPCS,OUTPATIENT,,,171,102.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,348.26,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,171,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7852.94,9504,
93976 PROF US DUPLEX SCAN FLOW LM,9539764,CDM,972,RC,93976,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,188.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,106.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7853.94,9505,
93784 PROF AMBULATORY BP MONITORIN,9543486,CDM,972,RC,93784,HCPCS,OUTPATIENT,,,217,130.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7854.94,9506,
19084 PROF US GUIDED BX BREAST ADD,9550241,CDM,972,RC,19084,HCPCS,OUTPATIENT,,,240,144,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,527.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,72.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7855.94,9507,
93978 PROF US RENAL DUPLEX DOPPLER,9567781,CDM,972,RC,93978,HCPCS,OUTPATIENT,,,118,70.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,236.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,118,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7856.94,9508,
93930 PROF US DUPLEX SCAN UPPER EX,9568839,CDM,972,RC,93930,HCPCS,OUTPATIENT,,,119,71.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,257.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,119,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7857.94,9509,
93931 PROF US UP EXT STUDY UNI/LMT,9568847,CDM,972,RC,93931,HCPCS,OUTPATIENT,,,75,45,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,160.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7858.94,9510,
38747 REMOVE ABDOMINAL LYMPH NODES,9600012,CDM,960,RC,38747,HCPCS,OUTPATIENT,,,834,500.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,477.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,253.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7859.94,9511,
97605 PROF NEG PRESS WOUND TX </=50 CM,9600024,CDM,960,RC,97605,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7860.94,9512,
51715 ENDO INJ OF IMPLANT MATERIA,9600032,CDM,960,RC,51715,HCPCS,OUTPATIENT,,,706,423.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,526.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,189.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7861.94,9513,
Intmd rpr s/a/t/ext 2.6-7.5,9600050,CDM,960,RC,12032,HCPCS,OUTPATIENT,,,579,347.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,325.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7862.94,9514,
97606 PROF NEG PRESS WND TX DME >50CM,9600057,CDM,960,RC,97606,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,25.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7863.94,9515,
97607 PROF NPWT NON DME </= 50 SQ CM,9600058,CDM,960,RC,97607,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,36.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7864.94,9516,
11451 Removal sweat gland lesion,9600060,CDM,960,RC,11451,HCPCS,OUTPATIENT,,,985,591,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,538.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,312.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7865.94,9517,
11102 Tangntl bx skin single les,9600067,CDM,960,RC,11102,HCPCS,OUTPATIENT,,,280,168,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,104.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7866.94,9518,
11443 PROF EXC FACE MM B9+MARG,9600073,CDM,960,RC,11443,HCPCS,OUTPATIENT,,,512,307.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,245.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,168.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7867.94,9519,
20206 BIOPSY MUSCLE PERCUTANEOUS NEEDLE,9600080,CDM,960,RC,20206,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,340.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7868.94,9520,
10005 FNA BX W/US GDN 1ST LES,9600085,CDM,960,RC,10005,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.37,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7869.94,9521,
15851 Suture or Staple Removal w/Anesthesia,9600101,CDM,960,RC,15851,HCPCS,OUTPATIENT,,,178,106.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,61.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7870.94,9522,
15853 Suture or Staple Removal w/o Anesthesia,9600103,CDM,960,RC,15853,HCPCS,OUTPATIENT,,,33,19.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,10.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7871.94,9523,
15854 Suture and  Staple Removal w/o Anesthesia,9600104,CDM,960,RC,15854,HCPCS,OUTPATIENT,,,46,27.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7872.94,9524,
43235 PROF EGD WITHOUT BIOPS,9600214,CDM,960,RC,43235,HCPCS,OUTPATIENT,,,670,402,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,420.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,115.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7873.94,9525,
46250 HEMORRHOIDECTOMY XTRNL 2/> GRP,9600220,CDM,960,RC,46250,HCPCS,OUTPATIENT,,,930,558,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,707.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,300.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7874.94,9526,
46255 HEMORRHOIDECTOMY INT/EXT 1 GRP,9600222,CDM,960,RC,46255,HCPCS,OUTPATIENT,,,1150,690,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,777.25,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,335.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7875.94,9527,
11042 DEBRIDEMENT SKIN SUBCUTANEOU,9600230,CDM,960,RC,11042,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,57.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7876.94,9528,
46946 Remove by ligat int hem grps,9600232,CDM,960,RC,46946,HCPCS,OUTPATIENT,,,670,402,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,478.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,355.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7877.94,9529,
49080 PERITONEOCENTESIS INITIAL,9600248,CDM,960,RC,49080,HCPCS,OUTPATIENT,,,380,228,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7878.94,9530,
49505 PROF REPAIR INTL INGUN HERNI,9600255,CDM,960,RC,49505,HCPCS,OUTPATIENT,,,1517,910.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,829.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,498.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7879.94,9531,
10061 ID OF ABCESS COMPLICATED,9600263,CDM,960,RC,10061,HCPCS,OUTPATIENT,,,515,309,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,225.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7880.94,9532,
10060 ID OF ABSCESS SIMPLE,9600271,CDM,960,RC,10060,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7881.94,9533,
11422 EXC BENIGN LESION 1.1-2.0CM,9600438,CDM,960,RC,11422,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,191.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7882.94,9534,
16020 DRESS/DEBRID P-THICK BURN SM,9600446,CDM,960,RC,16020,HCPCS,OUTPATIENT,,,220,132,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,87.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7883.94,9535,
11400 PROF EXC TR-EXT B9+MARG .5CM,9600453,CDM,960,RC,11400,HCPCS,OUTPATIENT,,,226,135.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,132.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7884.94,9536,
11426 PROF EX H-F-NK-SP B9+MARG>4C,9600461,CDM,960,RC,11426,HCPCS,OUTPATIENT,,,797,478.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,371.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,253.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7885.94,9537,
11424 EXC LESION 3.1CM TO 4.0CM,9600479,CDM,960,RC,11424,HCPCS,OUTPATIENT,,,517,310.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,256,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7886.94,9538,
25076 EXC TUMF/ARM/WRSTSFT TISS SUBFASC <3CM,9600500,CDM,960,RC,25076,HCPCS,OUTPATIENT,,,1540,924,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,802.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,493.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7887.94,9539,
25073 EXC TUM SFT TISS F/ARM and /WRIST SUBFASC 3CM/>,9600503,CDM,960,RC,25073,HCPCS,OUTPATIENT,,,1572,943.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,829.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,509.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7888.94,9540,
97535 SELF CARE TRAINING 15 MI,9600537,CDM,960,RC,97535,HCPCS,OUTPATIENT,,,90,54,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,25.09,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7889.94,9541,
43246 UGI PLMT GASTROSTOMY TUB,9600560,CDM,960,RC,43246,HCPCS,OUTPATIENT,,,590,354,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,322.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,188.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7890.94,9542,
10081 PROF ID PILONIDAL CYST COMP,9600818,CDM,960,RC,10081,HCPCS,OUTPATIENT,,,704,422.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,296.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,161.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7891.94,9543,
26111 PROF EXCISION HAND 1.5CM,9600909,CDM,960,RC,26111,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,645.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,395.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7892.94,9544,
29581 APPLY MULTLAY COMPRS LWR LEG,9601147,CDM,960,RC,29581,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,126.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,25.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7893.94,9545,
11045 DEB SUBQ TISSUE ADD-ON 20SQC,9601154,CDM,960,RC,11045,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,24.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7894.94,9546,
11043 DEB MUSC/FASCIA 20 SQ CM/<,9601162,CDM,960,RC,11043,HCPCS,OUTPATIENT,,,466,279.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,252.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7895.94,9547,
11046 DEB MUSC/FASCIA ADD-ON 20SQC,9601170,CDM,960,RC,11046,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,81.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7896.94,9548,
17250 CHEM CAUT GRANULATION TISSUE,9601188,CDM,960,RC,17250,HCPCS,OUTPATIENT,,,150,90,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,85.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7897.94,9549,
10140 ID HEMATOMA/FLUID COLLECTION,9601196,CDM,960,RC,10140,HCPCS,OUTPATIENT,,,326,195.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,111.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7898.94,9550,
19100 PROF CORE BRST EXCISIO,9601253,CDM,960,RC,19100,HCPCS,OUTPATIENT,,,304,182.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,164.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,65.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7899.94,9551,
55520 EXC LESION SPERMATIC CORD SEPARATE PROCEDURE BCE,9601520,CDM,960,RC,55520,HCPCS,OUTPATIENT,,,940,564,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,810.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,435.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7900.94,9552,
54161 PROF CIRCUM 28 DAYS OR OLDER,9601568,CDM,982,RC,54161,HCPCS,OUTPATIENT,,,575,345,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,350,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,187.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7901.94,9553,
20612 ASPIRATE/INJ GANGLION CYST,9602111,CDM,960,RC,20612,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7902.94,9554,
60220 TOTAL THYROID LOBECTOMY UNI,9602129,CDM,960,RC,60220,HCPCS,OUTPATIENT,,,2088,1252.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,969.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,672.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7903.94,9555,
68100 BIOPSY CONJUNCTIVA,9602180,CDM,960,RC,68100,HCPCS,OUTPATIENT,,,265,159,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,248.25,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,88.51,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7904.94,9556,
11402 EXC TR-EXT B9+MARG 1.1-2 CM,9602210,CDM,960,RC,11402,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7905.94,9557,
11606 EXC TR-EXT MAL+MARG >4 CM 6,9602285,CDM,960,RC,11606,HCPCS,OUTPATIENT,,,953,571.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,494.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,298.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7906.94,9558,
43239 PROF EGD WITH BIOPS,9602301,CDM,960,RC,43239,HCPCS,OUTPATIENT,,,778,466.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,559.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7907.94,9559,
45378 PROF DIAGNOSTIC COLONSCOP,9602319,CDM,960,RC,45378,HCPCS,OUTPATIENT,,,890,534,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,514.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7908.94,9560,
45380 PROF COLONOSCOPY W/BIOPSY,9602327,CDM,960,RC,45380,HCPCS,OUTPATIENT,,,1066,639.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,654.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,188.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7909.94,9561,
20605 DRAIN/INJ INTERM JNT/BURSA,9602350,CDM,960,RC,20605,HCPCS,OUTPATIENT,,,130,78,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7910.94,9562,
46045 I andD INTRAMURAL IM/ABSC TRANSANAL ANES,9602408,CDM,960,RC,46045,HCPCS,OUTPATIENT,,,1050,630,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,682.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,415.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7911.94,9563,
46083 INCISE THROMB HEMORRHOID EX,9602459,CDM,960,RC,46083,HCPCS,OUTPATIENT,,,309,185.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,272.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7912.94,9564,
45382 PROF COLSC FLX PROX SPLENIC FLXR CTRL BLD,9602466,CDM,960,RC,45382,HCPCS,OUTPATIENT,,,650,390,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1042.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,242.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7913.94,9565,
45384 PROF COLONOSCOPY FLX RMVL LE,9602467,CDM,960,RC,45384,HCPCS,OUTPATIENT,,,1054,632.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,731.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,214.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7914.94,9566,
49505 PRP I/HERN INIT REDUC>5YR,9602475,CDM,960,RC,49505,HCPCS,OUTPATIENT,,,1587,952.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,829.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,498.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7915.94,9567,
10180 ID CPLX POSTOP WND INFECTION,9602483,CDM,960,RC,10180,HCPCS,OUTPATIENT,,,535,321,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,271.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,167.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7916.94,9568,
49000 PROF EXPL LAPAROTOM,9602517,CDM,960,RC,49000,HCPCS,OUTPATIENT,,,2267,1360.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1234.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,731.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7917.94,9569,
26011 PROF DRAIN FINGER,9602525,CDM,960,RC,26011,HCPCS,OUTPATIENT,,,529,317.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,590.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,174.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7918.94,9570,
31502 PROF TRACH TB CHG B4 FISTULA,9602533,CDM,960,RC,31502,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.18,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7919.94,9571,
31605 TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE,9602540,CDM,960,RC,31605,HCPCS,OUTPATIENT,,,1058,634.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,533.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,314.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7920.94,9572,
38510 PROF OPEN BIOPSY/EXC DEEP CERVICAL NODE,9602550,CDM,960,RC,38510,HCPCS,OUTPATIENT,,,1060,636,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,883.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,397.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7921.94,9573,
11719 PROF TRIM ND NAILS,9602574,CDM,960,RC,11719,HCPCS,OUTPATIENT,,,25,15,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,15.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7922.94,9574,
38760 PROF INGUINOFEM LMPHADC SUPF,9602590,CDM,960,RC,38760,HCPCS,OUTPATIENT,,,2476,1485.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1475.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,796.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7923.94,9575,
49591 PROF RPR AA HRN 1ST <3CM RDC,9602591,CDM,960,RC,49591,HCPCS,OUTPATIENT,,,1020,612,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,326.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7924.94,9576,
49592 PROF RPR AA HRN 1ST <3CM NCR/STRN,9602592,CDM,960,RC,49592,HCPCS,OUTPATIENT,,,1425,855,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,454.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7925.94,9577,
49593 PROF RPR AA HRN 1ST 3-10CM RDC,9602593,CDM,960,RC,49593,HCPCS,OUTPATIENT,,,1715,1029,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,547.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7926.94,9578,
49594 PROF RPR AA HRN 1ST 3-10CM NCR/STRN,9602594,CDM,960,RC,49594,HCPCS,OUTPATIENT,,,2240,1344,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,713.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7927.94,9579,
49595 PROF RPR AA HRN 1ST >10CM RDC,9602595,CDM,960,RC,49595,HCPCS,OUTPATIENT,,,2310,1386,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,737.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7928.94,9580,
49596 PROF RPR AA HRN 1ST >10CM NCR/STRN,9602596,CDM,960,RC,49596,HCPCS,OUTPATIENT,,,3070,1842,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,978.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7929.94,9581,
49613 PROF RPR AA HRN RCR <3CM RDC,9602613,CDM,960,RC,49613,HCPCS,OUTPATIENT,,,1260,756,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,402.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7930.94,9582,
49614 PROF RPR AA HRN RCR <3CM NCR/STRN,9602614,CDM,960,RC,49614,HCPCS,OUTPATIENT,,,1715,1029,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,546.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7931.94,9583,
49615 PROF RPR AA HRN RCR 3-10CM RDC,9602615,CDM,960,RC,49615,HCPCS,OUTPATIENT,,,1915,1149,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,610.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7932.94,9584,
11442 EXC FACE-MM B9+MARG 1.1-2 C,9602616,CDM,960,RC,11442,HCPCS,OUTPATIENT,,,402,241.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,204.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7933.94,9585,
49616 PROF RPR AA HRN RCR 3-10CM NCR/STRN,9602617,CDM,960,RC,49616,HCPCS,OUTPATIENT,,,2575,1545,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,821.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7934.94,9586,
49617 PROF RPR AA HRN RCR >10CM RDC,9602618,CDM,960,RC,49617,HCPCS,OUTPATIENT,,,2650,1590,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,845.85,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7935.94,9587,
49618 PROF RPR AA HRN RCR >10CM NCR/STRN,9602619,CDM,960,RC,49618,HCPCS,OUTPATIENT,,,3720,2232,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1185.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7936.94,9588,
11750 TOENAIL MATRIX EXC PRM RMV,9602707,CDM,960,RC,11750,HCPCS,OUTPATIENT,,,503,301.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,166.61,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,96.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7937.94,9589,
43830 PROF GASTROSTOMY OP WO G,9602723,CDM,960,RC,43830,HCPCS,OUTPATIENT,,,2045,1227,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1118.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,668.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7938.94,9590,
36556 INSERT NON TUNNEL CV CATH,9602731,CDM,960,RC,36556,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,341.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,80.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7939.94,9591,
47600 REMOVAL OF GALLBLADDER,9602749,CDM,960,RC,47600,HCPCS,OUTPATIENT,,,4415,2649,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1716.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1019.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7940.94,9592,
11440 EXC BENIGN LESION 0.5CM OR L,9602756,CDM,960,RC,11440,HCPCS,OUTPATIENT,,,283,169.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,99.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7941.94,9593,
45330 SIGMOIDOSCOPY FLEX D,9602764,CDM,960,RC,45330,HCPCS,OUTPATIENT,,,305,183,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,249.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7942.94,9594,
11621 EXC MALIGNANT LES 0.6CM-1.0C,9602772,CDM,960,RC,11621,HCPCS,OUTPATIENT,,,492,295.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,248.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7943.94,9595,
47562 LAPAROSCOPY CHOLECYSTECOM,9602814,CDM,960,RC,47562,HCPCS,OUTPATIENT,,,1926,1155.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1053.85,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,629.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7944.94,9596,
47563 LAPARO CHOLECYSTECTOMY/GRAPH,9602815,CDM,960,RC,47563,HCPCS,OUTPATIENT,,,2070,1242,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1148.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,684.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7945.94,9597,
10160 PROF PNCT ASP ABSC HEMAT CYS,9602855,CDM,960,RC,10160,HCPCS,OUTPATIENT,,,276,165.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,90.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7946.94,9598,
11404 EXC BENIGN LESION 3.1CM-4.0,9602871,CDM,960,RC,11404,HCPCS,OUTPATIENT,,,459,275.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,239.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,154.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7947.94,9599,
11406 EXC BEN LES T/A/L >4.0CM,9602921,CDM,960,RC,11406,HCPCS,OUTPATIENT,,,655,393,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,347.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,234.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7948.94,9600,
28810 PROF AMP/METATARSAL TO,9602954,CDM,960,RC,28810,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,672.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,401.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7949.94,9601,
38500 OPEN BX OR EXC LN SUPERFICIA,9602962,CDM,960,RC,38500,HCPCS,OUTPATIENT,,,740,444,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,563.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,242.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7950.94,9602,
13101 CREP TRUNK 2.6-7.5CM,9603002,CDM,960,RC,13101,HCPCS,OUTPATIENT,,,874,524.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,430.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,230.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7951.94,9603,
43762 PROF REPLACEMENT GASTROSTOMY TUBE,9604000,CDM,960,RC,43762,HCPCS,OUTPATIENT,,,157,94.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,319.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7952.94,9604,
43763 PROF REPLACEMENT GASTROSTOMY TUBE,9604005,CDM,960,RC,43763,HCPCS,OUTPATIENT,,,340,204,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,476.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,82.54,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7953.94,9605,
19303 PROF MAST SIMPLE COMPLETE,9604018,CDM,960,RC,19303,HCPCS,OUTPATIENT,,,2800,1680,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1104.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,912.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7954.94,9606,
44125 ENTRC RESCJ SMALL INTESTINE W/ENTEROSTOMY,9604125,CDM,960,RC,44125,HCPCS,OUTPATIENT,,,3033,1819.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1898.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1118.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7955.94,9607,
44126 ENTRC RESCJ ATRESIA RESCJ  ANAST W/O TAPERING,9604126,CDM,960,RC,44126,HCPCS,OUTPATIENT,,,5140,3084,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3971.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2350.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7956.94,9608,
44160 PROF PR COLECTOMY W REM ILIU,9604166,CDM,960,RC,44160,HCPCS,OUTPATIENT,,,3500,2100,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1997.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1180.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7957.94,9609,
44143 PROF COLECTOMY PARTIAL,9604174,CDM,960,RC,44143,HCPCS,OUTPATIENT,,,4700,2820,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2676.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1567.28,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7958.94,9610,
38792 PROF SENTINEL NODE INJECTIO,9604208,CDM,960,RC,38792,HCPCS,OUTPATIENT,,,120,72,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,133.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,30.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7959.94,9611,
35221 RPR BLOOD VESSEL DIRECT INTRA-ABDOMINAL,9604221,CDM,960,RC,35221,HCPCS,OUTPATIENT,,,3640,2184,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2610.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1391.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7960.94,9612,
46600 PROF ANOSCOPY DX,9604224,CDM,960,RC,46600,HCPCS,OUTPATIENT,,,112,67.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,38.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7961.94,9613,
46940 CURTG/CAUT ANAL FISS W/DILAT SPHNCTR SPX 1ST,9604940,CDM,960,RC,46940,HCPCS,OUTPATIENT,,,430,258,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,357.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,137.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7962.94,9614,
19101 PROF OPEN INCISIONAL,9605825,CDM,960,RC,19101,HCPCS,OUTPATIENT,,,911,546.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,369.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,211.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7963.94,9615,
36561 INSERTION OF TUNNELED AGE 5>,9606815,CDM,960,RC,36561,HCPCS,OUTPATIENT,,,2655,1593,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1721.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,312.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7964.94,9616,
11730 AVULSION NAIL PLATE PARTIAL,9609116,CDM,960,RC,11730,HCPCS,OUTPATIENT,,,211,126.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,51.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7965.94,9617,
13160 PROF CLOSURE 2NDARY SUR,9609215,CDM,960,RC,13160,HCPCS,OUTPATIENT,,,2367,1420.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,903.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,751.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7966.94,9618,
14021 PF ADJ TISS TRNSF S/A/L 10.1-30 SQ CM,9609421,CDM,960,RC,14021,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,951.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,664.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7967.94,9619,
10040 RMVL/OPEN ACNE SEBCCYTS PST,9610049,CDM,960,RC,10040,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,49.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7968.94,9620,
21012 PROF EXC TUMOR SFT F/S 2CM,9610122,CDM,960,RC,21012,HCPCS,OUTPATIENT,,,967,580.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,526.69,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,320.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7969.94,9621,
10021 ASPIRATE FINE NDL W/O IMAGIN,9610213,CDM,960,RC,10021,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,106,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,52.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7970.94,9622,
19100 PROF BIOPSY BREAST NEEDL,9610239,CDM,960,RC,19100,HCPCS,OUTPATIENT,,,200,120,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,164.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,65.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7971.94,9623,
97597 SLCTV WND DEBRMENT 20CM/<,9611112,CDM,960,RC,97597,HCPCS,OUTPATIENT,,,100,60,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,33.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7972.94,9624,
44180 PROF LAP ENTEROLYSIS SUR,9611138,CDM,960,RC,44180,HCPCS,OUTPATIENT,,,2708,1624.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1478.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,876.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7973.94,9625,
11603 EXCISION MALIGNANT LESION,9611146,CDM,960,RC,11603,HCPCS,OUTPATIENT,,,564,338.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,307.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,180.91,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7974.94,9626,
11421 EXC BLES S/N/EX G;0.6-1.0CM,9611153,CDM,960,RC,11421,HCPCS,OUTPATIENT,,,319,191.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,169.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,102.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7975.94,9627,
11401 EXC BEN LES T/A/L;0.6-1.0CM,9611161,CDM,960,RC,11401,HCPCS,OUTPATIENT,,,290,174,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,162.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7976.94,9628,
11643 PROF EX F/E/E/N/LMAL+MRG2.1-,9611179,CDM,960,RC,11643,HCPCS,OUTPATIENT,,,673,403.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,347.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,213.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7977.94,9629,
97598 SLCTV WND DEBRIDEM ADDL 20C,9611187,CDM,960,RC,97598,HCPCS,OUTPATIENT,,,70,42,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,22.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7978.94,9630,
11200 EXCISION SKIN TAGS,9611237,CDM,960,RC,11200,HCPCS,OUTPATIENT,,,208,124.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,94.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7979.94,9631,
11201 EXCISION SKIN TAG ADDL 10,9611239,CDM,960,RC,11201,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,15.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7980.94,9632,
11311 PROF SHAVING LES FEEENL 0.6-,9611310,CDM,960,RC,11311,HCPCS,OUTPATIENT,,,267,160.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,59.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7981.94,9633,
36590 REM TUNNELED CVAD W PO,9611328,CDM,960,RC,36590,HCPCS,OUTPATIENT,,,612,367.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,376.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7982.94,9634,
11601 EXC MALIG LESION 0.6-1.0CM,9612219,CDM,960,RC,11601,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,246.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7983.94,9635,
21931 EXC BACK LES SC 3+CM,9612227,CDM,960,RC,21931,HCPCS,OUTPATIENT,,,1366,819.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,742.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,447.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7984.94,9636,
47100 PROF BIOPSY OF LIVER,9612235,CDM,960,RC,47100,HCPCS,OUTPATIENT,,,2326,1395.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1347.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,806.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7985.94,9637,
49180 PROF BIOPSY ABDOMINAL MASS P,9612243,CDM,960,RC,49180,HCPCS,OUTPATIENT,,,472,283.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,246.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,78.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7986.94,9638,
44005 PROF ENTEROLYSIS,9612318,CDM,960,RC,44005,HCPCS,OUTPATIENT,,,4465,2679,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1764.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1039.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7987.94,9639,
49553 PROF REPAIR INIT FEMORAL IN,9612342,CDM,960,RC,49553,HCPCS,OUTPATIENT,,,1780,1068,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1010.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,603.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7988.94,9640,
21555 PROF EXC NECK LES SC<3CM,9612920,CDM,960,RC,21555,HCPCS,OUTPATIENT,,,886,531.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,636.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,290.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7989.94,9641,
11403 EXC BENIGN EXC DIAM 2.1-3.0C,9613217,CDM,960,RC,11403,HCPCS,OUTPATIENT,,,421,252.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,210.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,140.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7990.94,9642,
11640 PROF EXC F/E/E/N/L MAL 0.,9613225,CDM,960,RC,11640,HCPCS,OUTPATIENT,,,362,217.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,216.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,118.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7991.94,9643,
11644 PROF EX MLES F/E/E/N/L3.1-4C,9613324,CDM,960,RC,11644,HCPCS,OUTPATIENT,,,835,501,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,430.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,264.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7992.94,9644,
11642 EXC MLES F/E/E/N/L 1.1-2.0C,9613332,CDM,960,RC,11642,HCPCS,OUTPATIENT,,,530,318,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,293.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7993.94,9645,
22903 PROF EXC ABD LES SC>3CM,9613423,CDM,960,RC,22903,HCPCS,OUTPATIENT,,,1258,754.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,694.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,419.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7994.94,9646,
11423 EXCISED DIAMETER 2.1 TO 3.,9613522,CDM,960,RC,11423,HCPCS,OUTPATIENT,,,452,271.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,220.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,147.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7995.94,9647,
26115 PROF EXC HAND LES SC>1.5C,9613621,CDM,960,RC,26115,HCPCS,OUTPATIENT,,,949,569.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,773.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,315.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7996.94,9648,
45388 PROF COLONOSCOPY FLEX W ABLA,9613720,CDM,960,RC,45388,HCPCS,OUTPATIENT,,,1058,634.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,4346.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,254.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7997.94,9649,
11646 EXC MLES F/E/E/N/L 1.1-2CM,9613829,CDM,960,RC,11646,HCPCS,OUTPATIENT,,,1164,698.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,565.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,366.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7998.94,9650,
36576 PROF REPAIR CVA DEV W PRT/PM,9613928,CDM,960,RC,36576,HCPCS,OUTPATIENT,,,585,351,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,537.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,171.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,7999.94,9651,
11444 PROF EXC BLES F/E/E/N/L 3.1-,9614447,CDM,960,RC,11444,HCPCS,OUTPATIENT,,,931,558.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,309.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,212.45,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8000.94,9652,
11446 PROF EXC BN LES F/E/E/N/M >,9614462,CDM,960,RC,11446,HCPCS,OUTPATIENT,,,950,570,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,431.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,299.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8001.94,9653,
11450 PROF EXC SKIN/SUBQ HIDR AXI,9614504,CDM,960,RC,11450,HCPCS,OUTPATIENT,,,1035,621,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,426.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,246.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8002.94,9654,
11470 PF EXC H/P/P/U SIMPLE/INTERM REPAIR,9614507,CDM,960,RC,11470,HCPCS,OUTPATIENT,,,820,492,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,457.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,270.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8003.94,9655,
41520 PROF FRENOPLAST,9615121,CDM,960,RC,41520,HCPCS,OUTPATIENT,,,749,449.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,525.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,235,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8004.94,9656,
21552 PROF EXC TUMOR SFT NECK/AT 3,9615527,CDM,960,RC,21552,HCPCS,OUTPATIENT,,,1724,1034.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,703.25,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,425.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8005.94,9657,
21554 PROF EXC TUMOR SFT N/TH 5C,9615543,CDM,960,RC,21554,HCPCS,OUTPATIENT,,,2975,1785,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1154.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,695.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8006.94,9658,
11604 PROF EXC MLES T/A/L 3.1-4.0C,9616046,CDM,960,RC,11604,HCPCS,OUTPATIENT,,,887,532.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,341.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,199.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8007.94,9659,
11624 PROF EXC MLES S/N/H/F/G;3.1-,9616244,CDM,960,RC,11624,HCPCS,OUTPATIENT,,,980,588,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,370.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,223.66,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8008.94,9660,
11626 EXC MALGNT S/N/H/F/G >4CM,9616269,CDM,960,RC,11626,HCPCS,OUTPATIENT,,,895,537,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,447.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,274.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8009.94,9661,
21933 PROF EXC TUMOR SFT B/F/SF 5C,9619339,CDM,960,RC,21933,HCPCS,OUTPATIENT,,,3045,1827,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1168.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,701.87,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8010.94,9662,
24073 Ex arm/elbow tum deep 5 cm/>,9620000,CDM,960,RC,24073,HCPCS,OUTPATIENT,,,2879,1727.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1092.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,658.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8011.94,9663,
38100 PROF SPLENECTOMY TOTAL,9620006,CDM,960,RC,38100,HCPCS,OUTPATIENT,,,3402,2041.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2039.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1095.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8012.94,9664,
43245 EGD DILATION GASTRIC/DUODENAL STRICTURE,9620010,CDM,960,RC,43245,HCPCS,OUTPATIENT,,,540,324,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,830.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8013.94,9665,
56405 PROF ID VULVA/PERINEAL ABSC,9620253,CDM,960,RC,56405,HCPCS,OUTPATIENT,,,319,191.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,177.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,119.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8014.94,9666,
28825 PROF AMPUTATION OF TOE,9621202,CDM,960,RC,28825,HCPCS,OUTPATIENT,,,355,213,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,812.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,165.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8015.94,9667,
64420 INJECTION AA/STRD NTRCOST NRV 1,9621220,CDM,960,RC,64420,HCPCS,OUTPATIENT,,,182,109.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,55.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8016.94,9668,
64421 INJECTION AA/STRD NTRCOST NRV EA ADD,9621221,CDM,960,RC,64421,HCPCS,OUTPATIENT,,,78,46.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,241.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,23.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8017.94,9669,
35860 EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR,9621230,CDM,960,RC,35860,HCPCS,OUTPATIENT,,,2595,1557,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1490.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,793.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8018.94,9670,
36556 INS NON-TUNNEL CV CATH 5YRS,9621236,CDM,960,RC,36556,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,341.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,80.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8019.94,9671,
11720 DEBRIDEMENT OF NAIL,9621327,CDM,960,RC,11720,HCPCS,OUTPATIENT,,,50,30,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,13.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8020.94,9672,
11000 DEBRIDE EXTENSV ECZEMA/INFEC,9621335,CDM,960,RC,11000,HCPCS,OUTPATIENT,,,115,69,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,59.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,26.5,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8021.94,9673,
44145 PROF COLECTOMY P W COLOPROC,9621509,CDM,960,RC,44145,HCPCS,OUTPATIENT,,,4917,2950.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2667.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1566.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8022.94,9674,
22010 PROF ID P SPINE C/T/CERV,9621616,CDM,960,RC,22010,HCPCS,OUTPATIENT,,,2762,1657.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1518.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,923.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8023.94,9675,
11622 PROF EXC S/N/H/F/G MAL+MR,9621715,CDM,960,RC,11622,HCPCS,OUTPATIENT,,,512,307.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,277.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,158.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8024.94,9676,
11620 PROF EXC H-F-NK-SP MAL+MARG 0.5/<,9621720,CDM,960,RC,11620,HCPCS,OUTPATIENT,,,376,225.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,210.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,115.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8025.94,9677,
28122 PF PRTL EXC TARSAL/METAR XCP TALUS/CALCNUS,9621902,CDM,960,RC,28122,HCPCS,OUTPATIENT,,,1050,630,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,910.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,417.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8026.94,9678,
28192 PROF REMOVAL FB FOOT DEE,9621921,CDM,960,RC,28192,HCPCS,OUTPATIENT,,,921,552.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,708.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,294.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8027.94,9679,
10035 PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE,9622300,CDM,960,RC,10035,HCPCS,OUTPATIENT,,,262,157.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,499.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,79.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8028.94,9680,
10080 ID PILONIDAL CYST SMPL,9622309,CDM,960,RC,10080,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8029.94,9681,
26951 PROF AMPUTATE FINGER,9623117,CDM,960,RC,26951,HCPCS,OUTPATIENT,,,1780,1068,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,970.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,653.38,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8030.94,9682,
23076 PROF EXC TUMOR SFT SHLD <5C,9630765,CDM,960,RC,23076,HCPCS,OUTPATIENT,,,1561,936.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,847.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,516.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8031.94,9683,
27345 REMOVAL OF KNEE CYST,9631581,CDM,960,RC,27345,HCPCS,OUTPATIENT,,,1917,1150.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,743.77,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,462.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8032.94,9684,
28190 REMOVAL OF FOOT FOREIGN BODY,9631620,CDM,960,RC,28190,HCPCS,OUTPATIENT,,,417,250.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,380,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,125.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8033.94,9685,
64788 Remove skin nerve lesion,9631625,CDM,960,RC,64788,HCPCS,OUTPATIENT,,,1190,714,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,664.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,387.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8034.94,9686,
44202 LAP ENTERECTOMY,9631628,CDM,960,RC,44202,HCPCS,OUTPATIENT,,,4305,2583,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2227.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1318.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8035.94,9687,
27337 EXC THIGH/KNEE LES SC 3 CM/,9631950,CDM,960,RC,27337,HCPCS,OUTPATIENT,,,1132,679.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,657.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,399.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8036.94,9688,
27630 REMOVAL OF TENDON LESION,9632176,CDM,960,RC,27630,HCPCS,OUTPATIENT,,,1165,699,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,834.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,339.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8037.94,9689,
11772 REMOVE PILONIDAL CYST COMPL,9632245,CDM,960,RC,11772,HCPCS,OUTPATIENT,,,2369,1421.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,773.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,545.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8038.94,9690,
53020 INCISION OF URETHRA,9632301,CDM,960,RC,53020,HCPCS,OUTPATIENT,,,400,240,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,168.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.52,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8039.94,9691,
43229 ESOPHAGOSCOPY LESION ABLATE,9632448,CDM,960,RC,43229,HCPCS,OUTPATIENT,,,853,511.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,976.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,184.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8040.94,9692,
Surgery Charges,9632459,CDM,960,RC,64792,HCPCS,OUTPATIENT,,,2718,1630.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1844.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1023.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8041.94,9693,
69110 REMOVE EXTERNAL EAR PARTIAL,9632461,CDM,960,RC,69110,HCPCS,OUTPATIENT,,,1132,679.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,501.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,305.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8042.94,9694,
11312 SHAVE SKIN LESION 1.1-2.0 CM,9632465,CDM,960,RC,11312,HCPCS,OUTPATIENT,,,323,193.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8043.94,9695,
43270 EGD LESION ABLATION,9632470,CDM,960,RC,43270,HCPCS,OUTPATIENT,,,1001,600.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1007.83,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,210.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8044.94,9696,
43248 EGD GUIDE WIRE INSERTION,9632476,CDM,960,RC,43248,HCPCS,OUTPATIENT,,,707,424.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,546.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,156.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8045.94,9697,
28005 INCISION BONE CORTEX FOOT,9632480,CDM,960,RC,28005,HCPCS,OUTPATIENT,,,541,324.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,897.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,541,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8046.94,9698,
27880 AMPUTATION OF LOWER LEG,9632482,CDM,960,RC,27880,HCPCS,OUTPATIENT,,,2850,1710,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1459.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,853.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8047.94,9699,
49321 LAPAROSCOPY BIOPSY,9632486,CDM,960,RC,49321,HCPCS,OUTPATIENT,,,1073,643.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,548.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,328.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8048.94,9700,
11305 SHAVE SKIN LESION 0.5 CM/<,9632493,CDM,960,RC,11305,HCPCS,OUTPATIENT,,,162,97.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8049.94,9701,
11306 SHAVE SKIN LESION 0.6-1.0 CM,9632496,CDM,960,RC,11306,HCPCS,OUTPATIENT,,,214,128.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,129.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,46.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8050.94,9702,
11307 SHAVE SKIN LESION 1.1-2.0 CM,9632499,CDM,960,RC,11307,HCPCS,OUTPATIENT,,,275,165,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,153.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,59.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8051.94,9703,
11301 SHAVE SKIN LESION 0.6-1.0 CM,9632501,CDM,960,RC,11301,HCPCS,OUTPATIENT,,,221,132.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8052.94,9704,
11302 SHAVE SKIN LESION 1.1-2.0 CM,9632504,CDM,960,RC,11302,HCPCS,OUTPATIENT,,,260,156,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,149.17,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,56.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8053.94,9705,
43284 LAPS ESOPHGL SPHNCTR AGMNTJ,9632507,CDM,960,RC,43284,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1030.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,621.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8054.94,9706,
46257 REMOVE IN/EX HEM GRP  FISS,9632510,CDM,960,RC,46257,HCPCS,OUTPATIENT,,,1306,783.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,662.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,392.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8055.94,9707,
11310 SHAVE SKIN LESION 0.5 CM/<,9632512,CDM,960,RC,11310,HCPCS,OUTPATIENT,,,146,87.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,120.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,42.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8056.94,9708,
46922 EXCISION OF ANAL LESIONS,9632515,CDM,960,RC,46922,HCPCS,OUTPATIENT,,,420,252,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,414.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8057.94,9709,
28043 EXC FOOT/TOE TUM SC < 1.5 CM,9632517,CDM,960,RC,28043,HCPCS,OUTPATIENT,,,1089,653.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,600.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,248.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8058.94,9710,
20525 RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP,9632519,CDM,960,RC,20525,HCPCS,OUTPATIENT,,,1023,613.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,708.49,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,233.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8059.94,9711,
11765 WEDGE EXCISION SKIN NAIL FOLD ProFee,9632520,CDM,960,RC,11765,HCPCS,OUTPATIENT,,,387,232.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,178.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,87.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8060.94,9712,
11771 REMOVE PILONIDAL CYST EXTEN,9632522,CDM,960,RC,11771,HCPCS,OUTPATIENT,,,1342,805.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,646.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,425.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8061.94,9713,
45100 BIOPSY OF RECTUM ProFee,9632525,CDM,960,RC,45100,HCPCS,OUTPATIENT,,,930,558,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,466.84,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,286.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8062.94,9714,
30000 DRAINAGE OF NOSE LESION,9632528,CDM,960,RC,30000,HCPCS,OUTPATIENT,,,361,216.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,349.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,113.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8063.94,9715,
19110 NIPPLE EXPLORATION,9632530,CDM,960,RC,19110,HCPCS,OUTPATIENT,,,1058,634.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,533.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,333.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8064.94,9716,
46221 LIGATION OF HEMORRHOID,9632532,CDM,960,RC,46221,HCPCS,OUTPATIENT,,,590,354,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,406.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,179.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8065.94,9717,
21932  EXC BACK TUM DEEP < 5 CM,9632535,CDM,960,RC,21932,HCPCS,OUTPATIENT,,,2055,1233,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1045.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,630.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8066.94,9718,
11976 REMOVE CONTRACEPTIVE CAPSULE,9632537,CDM,960,RC,11976,HCPCS,OUTPATIENT,,,291,174.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,157.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,88.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8067.94,9719,
40490 Biopsy of Lip,9632538,CDM,960,RC,40490,HCPCS,OUTPATIENT,,,373,223.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,188.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,65.44,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8068.94,9720,
67840 REMOVE EYELID LESION,9632539,CDM,960,RC,67840,HCPCS,OUTPATIENT,,,483,289.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,394.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8069.94,9721,
44110 EXCISE INTESTINE LESION(S),9632542,CDM,960,RC,44110,HCPCS,OUTPATIENT,,,2597,1558.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1361.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,809.08,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8070.94,9722,
38570 LAPAROSCOPY LYMPH NODE BIOP,9632544,CDM,960,RC,38570,HCPCS,OUTPATIENT,,,1570,942,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,886.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,491.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8071.94,9723,
38531 OPEN BIOPSY/EXCISION INGUINOFEMORAL NODES,9632547,CDM,960,RC,38531,HCPCS,OUTPATIENT,,,1330,798,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,755.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,425.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8072.94,9724,
43880 CLOSURE GASTROCOLIC FISTULA,9632550,CDM,960,RC,43880,HCPCS,OUTPATIENT,,,4100,2460,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2568.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1531.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8073.94,9725,
43279 PROF LAP SURG ESPHAG FUNDOPL,9632803,CDM,960,RC,43279,HCPCS,OUTPATIENT,,,4420,2652,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2082.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1221.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8074.94,9726,
C9739 Cystoscopy prostatic imp 1-3,9632805,CDM,982,RC,C9739,HCPCS,OUTPATIENT,,,1500,900,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8075.94,9727,
C9740 Cysto impl 4 or more,9632810,CDM,982,RC,C9740,HCPCS,OUTPATIENT,,,2500,1500,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2500,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8076.94,9728,
43289 PROF UNLIST LAP PROC ESOP,9632894,CDM,960,RC,43289,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8077.94,9729,
43450 PROF DILATION ESOPHAGUS,9634502,CDM,960,RC,43450,HCPCS,OUTPATIENT,,,495,297,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,259.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,74.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8078.94,9730,
23930 PROF ID UPPERARM-AXI-ELB D,9639303,CDM,960,RC,23930,HCPCS,OUTPATIENT,,,885,531,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,532.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,204.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8079.94,9731,
54001 SLITTING PREPUCE DORSAL/LAT SPX XCP NEWBORN,9641601,CDM,960,RC,54001,HCPCS,OUTPATIENT,,,406,243.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,325.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,133.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8080.94,9732,
54162 PROF LYSIS/EXC PENILE ADH,9641622,CDM,960,RC,54162,HCPCS,OUTPATIENT,,,817,490.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,446.23,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,190.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8081.94,9733,
54164 PROF FRENULOTOMY OF PENI,9641648,CDM,960,RC,54164,HCPCS,OUTPATIENT,,,785,471,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,339.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,183.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8082.94,9734,
44207 PROF LAP SURGICAL COLECTOM,9642075,CDM,960,RC,44207,HCPCS,OUTPATIENT,,,7531,4518.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2921.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1715.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8083.94,9735,
46610 PROF ANOSCOPY W REMOVE HOT/C,9646100,CDM,960,RC,46610,HCPCS,OUTPATIENT,,,239,143.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,353.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8084.94,9736,
44626 PROF CLOSURE ENTEROSTOMY HAR,9646266,CDM,960,RC,44626,HCPCS,OUTPATIENT,,,6670,4002,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2582.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1510.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8085.94,9737,
49999 PROF UNLISTED PROCE ABD/PE,9649997,CDM,960,RC,49999,HCPCS,OUTPATIENT,,,2075,1245,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8086.94,9738,
55040 PROF EXC HYDROCELE;UNIL,9650409,CDM,960,RC,55040,HCPCS,OUTPATIENT,,,970,582,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,597.99,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,322.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8087.94,9739,
45171 PROF EXC RECTAL TUMOR TRANSA,9651712,CDM,960,RC,45171,HCPCS,OUTPATIENT,,,2460,1476,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,942.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,579.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8088.94,9740,
11420 PROF EXC BLES S/N/EXG 0.5CM,9653247,CDM,960,RC,11420,HCPCS,OUTPATIENT,,,230,138,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,132.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8089.94,9741,
17106 DSTR CUTANEOUS VASC PROLIFERATIVE <10CM,9653266,CDM,960,RC,17106,HCPCS,OUTPATIENT,,,800,480,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,373.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,258.99,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8090.94,9742,
45338 PROF SIGMOIDOSCOPY FLEX SNAR,9653387,CDM,960,RC,45338,HCPCS,OUTPATIENT,,,580,348,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,408.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,112.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8091.94,9743,
45346 PROF SIGMOIDSCOPY FLEX SNAR,9653395,CDM,960,RC,45346,HCPCS,OUTPATIENT,,,573,343.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,4106.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8092.94,9744,
45305 PROCTOSIGMOIDOSCOPY W/BX SNG,9660218,CDM,960,RC,45305,HCPCS,OUTPATIENT,,,395,237,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,227.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,68.79,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8093.94,9745,
46040 PROF ID ISCHIORECTAL/PERIRE,9660408,CDM,960,RC,46040,HCPCS,OUTPATIENT,,,1683,1009.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,821.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,401.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8094.94,9746,
"46080 PROF SPHINCTERTOMY,ANA",9660804,CDM,960,RC,46080,HCPCS,OUTPATIENT,,,657,394.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,391.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,150.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8095.94,9747,
99284 EMERGENCY DEPT VISIT PROF,9661026,CDM,960,RC,99284,HCPCS,OUTPATIENT,,,356,213.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8096.94,9748,
44970 PROF LAPAROSCOPY APPENDECTOM,9661125,CDM,960,RC,44970,HCPCS,OUTPATIENT,,,1756,1053.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,961.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,574.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8097.94,9749,
49525 PROF REPAIR INGUINAL HERNI,9661521,CDM,960,RC,49525,HCPCS,OUTPATIENT,,,1786,1071.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,915.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,547.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8098.94,9750,
54520 ORCHIECTOMY SMPL W/WO TESTI,9661620,CDM,960,RC,54520,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,579.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,312.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8099.94,9751,
46050 ID PERIANAL ABSCESS SUPFCL,9661927,CDM,960,RC,46050,HCPCS,OUTPATIENT,,,396,237.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,308.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,95.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8100.94,9752,
27882 AMPUTATION OPEN CIRCULAR LE,9662149,CDM,960,RC,27882,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,952.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,561.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8101.94,9753,
46220 PROF EXC SINGLE PAP/TAG/ANU,9662206,CDM,960,RC,46220,HCPCS,OUTPATIENT,,,495,297,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,323.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,114.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8102.94,9754,
46261 PROF HEMORRHOID INT/EXT W FI,9662610,CDM,960,RC,46261,HCPCS,OUTPATIENT,,,2158,1294.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,820.04,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,505.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8103.94,9755,
46275 PROF SURG TX ANAL FIST INTER,9662750,CDM,960,RC,46275,HCPCS,OUTPATIENT,,,1199,719.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,825.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,398.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8104.94,9756,
27590 AMPUTATION THIGH THRU FEMUR,9663212,CDM,960,RC,27590,HCPCS,OUTPATIENT,,,2400,1440,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1275.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,745.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8105.94,9757,
28820 PROF AMPUTATE TOE MTP JOIN,9665225,CDM,960,RC,28820,HCPCS,OUTPATIENT,,,1170,702,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,851.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,169.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8106.94,9758,
45385 PROF COLONOSCOPY FLEX W RE,9665233,CDM,960,RC,45385,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,695.01,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,238.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8107.94,9759,
43200 PROF ESOPHAGOSCOPY DIAGNOST,9665241,CDM,960,RC,43200,HCPCS,OUTPATIENT,,,300,180,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,334.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,82.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8108.94,9760,
27385 PROF SUTURE QUAD/HAMSTRIN,9665258,CDM,960,RC,27385,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,890.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8109.94,9761,
43280 PROF LAP ESOPHAGOGASTI,9665266,CDM,960,RC,43280,HCPCS,OUTPATIENT,,,3040,1824,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1740.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1026.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8110.94,9762,
47379 PROF UNLISTED LAP LIVER,9665274,CDM,960,RC,47379,HCPCS,OUTPATIENT,,,1300,780,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8111.94,9763,
46230 PROF EXC OF MULP EXT PAPILL,9665282,CDM,960,RC,46230,HCPCS,OUTPATIENT,,,775,465,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,426.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,164.78,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8112.94,9764,
49507 PROF INCARCERATED/STRANGULA,9665290,CDM,960,RC,49507,HCPCS,OUTPATIENT,,,1643,985.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,935.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,560.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8113.94,9765,
44950 PROF APPENDECTOMY,9665332,CDM,960,RC,44950,HCPCS,OUTPATIENT,,,1888,1132.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1032.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,612.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8114.94,9766,
36589 PROF REMOVAL TUNNEL CVC W/,9665894,CDM,960,RC,36589,HCPCS,OUTPATIENT,,,575,345,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,277.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,127.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8115.94,9767,
49521 PROF REPAIR RECUR ING HERNI,9667536,CDM,960,RC,49521,HCPCS,OUTPATIENT,,,2100,1260,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1148.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,684.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8116.94,9768,
46945 PROF HEMORRHOIDECTOMY INT SI,9669458,CDM,960,RC,46945,HCPCS,OUTPATIENT,,,635,381,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,471,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,317.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8117.94,9769,
27087 PROF REMOVAL FB PELVIS/HIP DEEP,9670878,CDM,960,RC,27087,HCPCS,OUTPATIENT,,,1820,1092,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,962.05,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,585.98,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8118.94,9770,
49520 PROF REPAIR RECURRING HERNI,9671520,CDM,960,RC,49520,HCPCS,OUTPATIENT,,,1780,1068,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1011.42,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,604.83,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8119.94,9771,
57300 PROF CLOSE RECTOVAGINAL FIST,9673005,CDM,960,RC,57300,HCPCS,OUTPATIENT,,,2307,1384.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,913.27,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,580.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8120.94,9772,
23071 PROF EXC SHOULDER LES SC>3CM,9673518,CDM,960,RC,23071,HCPCS,OUTPATIENT,,,1212,727.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,659.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,399.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8121.94,9773,
44625 PROF CLOSE ENTEROSTOMY W,9673534,CDM,960,RC,44625,HCPCS,OUTPATIENT,,,2900,1740,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1627.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,958.96,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8122.94,9774,
35840 PROF EXPL POSTOP HEMOR/THR,9673542,CDM,960,RC,35840,HCPCS,OUTPATIENT,,,3300,1980,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2115.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1151.69,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8123.94,9775,
20103 PROF EXPL P WIND EXTRE,9673559,CDM,960,RC,20103,HCPCS,OUTPATIENT,,,980,588,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,873.08,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,327.17,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8124.94,9776,
57410 PROF PELVIC EX UND ANEST,9674102,CDM,960,RC,57410,HCPCS,OUTPATIENT,,,446,267.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,169.76,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8125.94,9777,
27596 PROF AMPUTATION THI-FEM REAM,9675968,CDM,960,RC,27596,HCPCS,OUTPATIENT,,,3007,1804.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1142.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,674.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8126.94,9778,
43234 PROF UGI SIMPLE PRIMARY EXA,9680000,CDM,960,RC,43234,HCPCS,OUTPATIENT,,,355,213,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8127.94,9779,
11732 PROF SPL AVULSE NP EA ADDT,9680109,CDM,960,RC,11732,HCPCS,OUTPATIENT,,,80,48,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,16.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8128.94,9780,
21930 PROF EXC BACK LES SC<3 C,9680117,CDM,960,RC,21930,HCPCS,OUTPATIENT,,,1056,633.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,734.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,346.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8129.94,9781,
24071 PROF EXC ARM ELBOW LES SC,9680125,CDM,960,RC,24071,HCPCS,OUTPATIENT,,,1200,720,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,637.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,385.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8130.94,9782,
11623 PROF EXC MLES S/N EXT2 1-3C,9680133,CDM,960,RC,11623,HCPCS,OUTPATIENT,,,600,360,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,326.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,196.23,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8131.94,9783,
25071 PROF EXC FOREARM LES SC 3C,9680141,CDM,960,RC,25071,HCPCS,OUTPATIENT,,,1245,747,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,665.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,404,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8132.94,9784,
15830 PROF EXC EXCESS SKIN/SUBQ AB,9680364,CDM,960,RC,15830,HCPCS,OUTPATIENT,,,3436,2061.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1325.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1105.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8133.94,9785,
28090 PROF EXC LES/TEN/TS/CAP FOO,9680901,CDM,960,RC,28090,HCPCS,OUTPATIENT,,,900,540,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,709.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,293.25,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8134.94,9786,
45990 PROF SURG DX EXAM ANORECTA,9681008,CDM,960,RC,45990,HCPCS,OUTPATIENT,,,307,184.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100.3,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8135.94,9787,
10120 PROF INC  REM FB SQ SIMPL,9681305,CDM,960,RC,10120,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,162,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8136.94,9788,
10080 PROF INCISION AND DRAINAG,9681461,CDM,960,RC,10080,HCPCS,OUTPATIENT,,,335,201,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,194.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,98.4,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8137.94,9789,
11104 Punch Biopsy of Skin single lesion,9681498,CDM,960,RC,11104,HCPCS,OUTPATIENT,,,293,175.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,131.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,44.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8138.94,9790,
56440 PROF MARSUPIALIZATION GLAN,9681503,CDM,960,RC,56440,HCPCS,OUTPATIENT,,,520,312,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,285.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8139.94,9791,
11200 PROF REMOVAL OF SKIN TAG,9681511,CDM,960,RC,11200,HCPCS,OUTPATIENT,,,240,144,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,94.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,71.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8140.94,9792,
48500 PROF MARSUPIALIZE PANCREATI,9685009,CDM,960,RC,48500,HCPCS,OUTPATIENT,,,4687,2812.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1847.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1092.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8141.94,9793,
43281 PROF LAPAROSCOPY SURGICA,9685116,CDM,960,RC,43281,HCPCS,OUTPATIENT,,,4400,2640,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2495.44,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1463.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8142.94,9794,
43282 PROF LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH,9685118,CDM,960,RC,43282,HCPCS,OUTPATIENT,,,2750,1650,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2808.15,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1648.49,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8143.94,9795,
44144 PROF RESECTION WITH COLOSTO,9685207,CDM,960,RC,44144,HCPCS,OUTPATIENT,,,5233,3139.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2849.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1673.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8144.94,9796,
60240 PROF THYROIDECTOMY TOTA,9685215,CDM,960,RC,60240,HCPCS,OUTPATIENT,,,2716,1629.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1269.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,873.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8145.94,9797,
38525 PROF BIOPSY/EXC LYMPH ND OP,9685256,CDM,960,RC,38525,HCPCS,OUTPATIENT,,,1268,760.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,760.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,419.2,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8146.94,9798,
58720 PROF SALPINGO OOPHRECTOMY U/,9687203,CDM,960,RC,58720,HCPCS,OUTPATIENT,,,2262,1357.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1192.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,724.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8147.94,9799,
19000 PROF PUNCTURE ASP CYST BREAS,9690009,CDM,960,RC,19000,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.92,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,40.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8148.94,9800,
46320 PROF REMOVAL OF HEMORRHOI,9690108,CDM,960,RC,46320,HCPCS,OUTPATIENT,,,307,184.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,284.63,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,107.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8149.94,9801,
16030 PROF DRESS/DEBD BRN PART THC,9690306,CDM,960,RC,16030,HCPCS,OUTPATIENT,,,420,252,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.1,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8150.94,9802,
11044 PROF DEBRIDEMENT BONE/EPI/DE,9690447,CDM,960,RC,11044,HCPCS,OUTPATIENT,,,695,417,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,346.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,214.34,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8151.94,9803,
19083 PROF BIOPSY BREAST USGUID,9690835,CDM,960,RC,19083,HCPCS,OUTPATIENT,,,525,315,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,664.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8152.94,9804,
43247 PROF EGD WITH REMOVAL F,9692476,CDM,960,RC,43247,HCPCS,OUTPATIENT,,,556,333.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,534.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,166.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8153.94,9805,
19285 PROF PLACE BREAST DEV W U,9692856,CDM,960,RC,19285,HCPCS,OUTPATIENT,,,270,162,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,503.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,79.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8154.94,9806,
49320 PROF LAPAROSCOPY ABD DIAGNOS,9693201,CDM,960,RC,49320,HCPCS,OUTPATIENT,,,995,597,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,518.17,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,313.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8155.94,9807,
49557 PROF REPAIR REC FEM HERN INC,9695578,CDM,960,RC,49557,HCPCS,OUTPATIENT,,,3002,1801.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1160.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,689.89,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8156.94,9808,
49905 PROF OMENTAL FLAP INTRA-ABDOMINAL,9696505,CDM,960,RC,49905,HCPCS,OUTPATIENT,,,995,597,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,573.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,335.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8157.94,9809,
44204 PROF COLECTOMY PART W ANAST,9696576,CDM,960,RC,44204,HCPCS,OUTPATIENT,,,6318,3790.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2474.71,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1456.76,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8158.94,9810,
44213 PROF LAP MOBILIZATION OF SPE,9696584,CDM,960,RC,44213,HCPCS,OUTPATIENT,,,777,466.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,304.33,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,176.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8159.94,9811,
49659 PROF LAP UNLIST HERNIA REPAI,9696592,CDM,960,RC,49659,HCPCS,OUTPATIENT,,,5460,3276,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other ,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8160.94,9812,
44602 PROF SUTURE SM INTESTINE SINGLE PERF,9699018,CDM,960,RC,44602,HCPCS,OUTPATIENT,,,4181,2508.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2283.66,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1339.24,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8161.94,9813,
19120 REMOVAL OF BREAST LESIO,9699034,CDM,960,RC,19120,HCPCS,OUTPATIENT,,,1150,690,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,556.36,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,397.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8162.94,9814,
20520 PROF REMOVAL OF FOREIGN BOD,9699042,CDM,960,RC,20520,HCPCS,OUTPATIENT,,,570,342,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,307.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,139.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8163.94,9815,
15100 PROF SPLIT THICKNESS GRAF,9699083,CDM,960,RC,15100,HCPCS,OUTPATIENT,,,2580,1548,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,948.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,673.04,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8164.94,9816,
43215 PROF REMOVAL OF FOREIGN BOD,9699091,CDM,960,RC,43215,HCPCS,OUTPATIENT,,,460,276,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,546.59,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,133.13,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8165.94,9817,
21920 PROF BIOPSY S/T BACK OR FLAN,9699117,CDM,960,RC,21920,HCPCS,OUTPATIENT,,,550,330,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,380.6,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.82,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8166.94,9818,
G0121 PROF SCREENING COLOSCOPY,9699125,CDM,960,RC,G0121,HCPCS,OUTPATIENT,,,640,384,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,514.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8167.94,9819,
28805 PROF AMPUTATION FOOT TRNSMET,9699133,CDM,960,RC,28805,HCPCS,OUTPATIENT,,,2215,1329,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1146.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,673.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8168.94,9820,
40804 PROF REMOVAL FB VISTIBUL,9699141,CDM,960,RC,40804,HCPCS,OUTPATIENT,,,375,225,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,282.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,106.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8169.94,9821,
49002 PROF REOPENING OF RECENT LA,9699158,CDM,960,RC,49002,HCPCS,OUTPATIENT,,,2937,1762.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1684.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,992.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8170.94,9822,
49082 PROF ABDOMINAL PARACENTESI,9699166,CDM,960,RC,49082,HCPCS,OUTPATIENT,,,490,294,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,291.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8171.94,9823,
25111 PROF EXCISION OF GANGLIO,9699182,CDM,960,RC,25111,HCPCS,OUTPATIENT,,,890,534,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,490.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,309.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8172.94,9824,
46260 PROF HEMORRHOIDECTOMY INTE,9699190,CDM,960,RC,46260,HCPCS,OUTPATIENT,,,1340,804,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,748.93,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,455.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8173.94,9825,
45333 PROF SIGMOID FLX W/REM LESIO,9699216,CDM,960,RC,45333,HCPCS,OUTPATIENT,,,315,189,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,443.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,88.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8174.94,9826,
10121 PROF INC AND REMOVAL FB S,9699224,CDM,960,RC,10121,HCPCS,OUTPATIENT,,,541,324.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,295.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.36,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8175.94,9827,
17110 PROF DESTRUCT BENIGN LESION,9699232,CDM,960,RC,17110,HCPCS,OUTPATIENT,,,356,213.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.39,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,63.58,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8176.94,9828,
46200 PROF FISSURECTOMY W/WO SP,9699240,CDM,960,RC,46200,HCPCS,OUTPATIENT,,,1500,900,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,678.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,316.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8177.94,9829,
36595 PROF MECHANICAL REMOVAL CAT,9699257,CDM,960,RC,36595,HCPCS,OUTPATIENT,,,1730,1038,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,972.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,170.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8178.94,9830,
23073 PROF EXC TUMOR SFT SHOULD 5,9699273,CDM,960,RC,23073,HCPCS,OUTPATIENT,,,1900,1140,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1095.06,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,662.46,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8179.94,9831,
91035 PROF ESOPHAGUS GERD TEST P,9699281,CDM,960,RC,91035,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,601.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8180.94,9832,
49555 PROF REPAIR REC FEMORA HERNI,9699299,CDM,960,RC,49555,HCPCS,OUTPATIENT,,,1800,1080,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,956.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,577.05,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8181.94,9833,
11441 PROF EXC FACE-MM B9 MAR,9699315,CDM,960,RC,11441,HCPCS,OUTPATIENT,,,370,222,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,182.67,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.55,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8182.94,9834,
58805 PROF DRAIN OVARY CYST U/B AB,9699323,CDM,960,RC,58805,HCPCS,OUTPATIENT,,,2000,1200,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,641.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,407.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8183.94,9835,
43653 PROF LAP SURG GASTROSTOMY W/,9699331,CDM,960,RC,43653,HCPCS,OUTPATIENT,,,1700,1020,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,911.88,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,549.56,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8184.94,9836,
52442 Cystourethro w/addl implant,9699337,CDM,982,RC,52442,HCPCS,OUTPATIENT,,,250,150,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1485.12,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,47.88,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8185.94,9837,
15847 EXC SKIN ABD ADD-ON,9699339,CDM,982,RC,15847,HCPCS,OUTPATIENT,,,1069,641.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,412.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8186.94,9838,
52224 CYSTOSCOPY AND TREATMENT,9699340,CDM,982,RC,52224,HCPCS,OUTPATIENT,,,841,504.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1172.22,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,191.59,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8187.94,9839,
54450 Preputial Stretching,9699343,CDM,982,RC,54450,HCPCS,OUTPATIENT,,,180,108,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,121.87,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,54.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8188.94,9840,
21235 EAR CARTILAGE GRAFT,9699345,CDM,982,RC,21235,HCPCS,OUTPATIENT,,,1754,1052.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1095.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,536.95,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8189.94,9841,
50389  REMOVE RENAL TUBE W/FLUORO,9699347,CDM,982,RC,50389,HCPCS,OUTPATIENT,,,170,102,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,525.25,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,50.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8190.94,9842,
32555 PROF THORACENTESIS FOR AS,9699349,CDM,960,RC,32555,HCPCS,OUTPATIENT,,,455,273,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,436.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,103.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8191.94,9843,
51710 CHANGE OF BLADDER TUBE,9699350,CDM,982,RC,51710,HCPCS,OUTPATIENT,,,376,225.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,212.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,75.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8192.94,9844,
69000 PROF DR EXT EAR ABSCESS/HE,9699356,CDM,960,RC,69000,HCPCS,OUTPATIENT,,,336,201.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,203.95,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,117.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8193.94,9845,
49550 PROF REP INIT FEMORAL HER,9699364,CDM,960,RC,49550,HCPCS,OUTPATIENT,,,1590,954,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,920.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,551.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8194.94,9846,
43840 PROF GASTRORRHAPHY SUTUR,9699372,CDM,960,RC,43840,HCPCS,OUTPATIENT,,,3760,2256,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2191.55,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1295.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8195.94,9847,
43752 PF NASO/ORO-GASTRIC TUBE PLMT,9699397,CDM,960,RC,43752,HCPCS,OUTPATIENT,,,125,75,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,64.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,37.97,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8196.94,9848,
43753 PROF TX GASTRO INTUB W/ASP,9699398,CDM,960,RC,43753,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,35.11,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,20.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8197.94,9849,
44120 PROF RESECT SM INTEST SG,9699406,CDM,960,RC,44120,HCPCS,OUTPATIENT,,,3612,2167.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1972.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1163.43,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8198.94,9850,
44388 PROF COLONOSCOPY THRU STOM,9699414,CDM,960,RC,44388,HCPCS,OUTPATIENT,,,500,300,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,441.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8199.94,9851,
54522 ORCHIECTOMY PARTIAL,9699415,CDM,982,RC,54522,HCPCS,OUTPATIENT,,,2554,1532.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1048.9,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,558.7,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8200.94,9852,
44140 PROF COLECTOMY PARTIALW/ANA,9699422,CDM,960,RC,44140,HCPCS,OUTPATIENT,,,3800,2280,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2160.25,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1276.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8201.94,9853,
44139 TAKE-DOWN SPLEN FLEXUR,9699430,CDM,960,RC,44139,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,196.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,114.01,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8202.94,9854,
45331 PROF SIGMOIDOSCOPY FLEX B,9699448,CDM,960,RC,45331,HCPCS,OUTPATIENT,,,225,135,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,386.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,67.8,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8203.94,9855,
44603 PROF SUTURE SM INTESTINE MULTPL PERF,9699454,CDM,960,RC,44603,HCPCS,OUTPATIENT,,,4500,2700,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2616.29,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1537.29,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8204.94,9856,
44604 PROF SUTURE OF LARGE INTES,9699455,CDM,960,RC,44604,HCPCS,OUTPATIENT,,,3125,1875,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1707.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1003.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8205.94,9857,
22905 PROF RADICAL RESECTION TUMO,9699463,CDM,960,RC,22905,HCPCS,OUTPATIENT,,,3923,2353.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2129.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1265.27,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8206.94,9858,
27043 PROF EX TUMOR SFT TISSUE/PEL,9699505,CDM,960,RC,27043,HCPCS,OUTPATIENT,,,1362,817.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,741.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,447.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8207.94,9859,
44320 PROF COLOSTOM,9699513,CDM,960,RC,44320,HCPCS,OUTPATIENT,,,3900,2340,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1929.47,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1140.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8208.94,9860,
44310 PROF ILEOSTOMY/JEJUNOSTOM,9699521,CDM,960,RC,44310,HCPCS,OUTPATIENT,,,3089,1853.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1674.2,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,987.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8209.94,9861,
19020 PROF MASTOTOMY W EXPL DEE,9699539,CDM,960,RC,19020,HCPCS,OUTPATIENT,,,874,524.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,511.38,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,295.81,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8210.94,9862,
25075 PROF EXC FOREARM LES SC<3C,9699554,CDM,960,RC,25075,HCPCS,OUTPATIENT,,,909,545.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,737.07,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,299.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8211.94,9863,
24075 PROF EXC ARM/ELBOW LES <3C,9699562,CDM,960,RC,24075,HCPCS,OUTPATIENT,,,949,569.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,758.24,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,312.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8212.94,9864,
44340 PROF REVISE COLOSTOMY SIMPL,9699570,CDM,960,RC,44340,HCPCS,OUTPATIENT,,,1826,1095.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,987.82,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,597.22,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8213.94,9865,
21011 PROF EXC FACE LES SC <2 CM,9699588,CDM,960,RC,21011,HCPCS,OUTPATIENT,,,734,440.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,529.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,244.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8214.94,9866,
45915 PROF RMVL FECAL IMPACTION,9699596,CDM,960,RC,45915,HCPCS,OUTPATIENT,,,659,395.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,509.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,215.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8215.94,9867,
11602 PROF EXC TR-EXT MAL+MARG 1,9699604,CDM,960,RC,11602,HCPCS,OUTPATIENT,,,870,522,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,267.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,151.02,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8216.94,9868,
27886 PROF LEG TIBIA/FIBULA REAMPU,9699612,CDM,960,RC,27886,HCPCS,OUTPATIENT,,,1952,1171.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1037.91,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,614.31,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8217.94,9869,
44800 PROF EXC MECKELS DIVERTIC,9699620,CDM,960,RC,44800,HCPCS,OUTPATIENT,,,2150,1290,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1225.28,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,739.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8218.94,9870,
37609 PROF LIG/BPSY TEMPORAL ARTER,9699638,CDM,960,RC,37609,HCPCS,OUTPATIENT,,,615,369,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,514.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,192.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8219.94,9871,
43251 PROF UGI W REM T/P/LES,9699646,CDM,960,RC,43251,HCPCS,OUTPATIENT,,,623,373.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,676.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,183.9,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8220.94,9872,
G0120 PROF COLONOSCOPY SCREENING,9699653,CDM,960,RC,G0120,HCPCS,OUTPATIENT,,,144,86.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,200.48,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,141.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8221.94,9873,
45379 PROF COLSC FLX W/RMVL OF FOREIGN BODY(S),9699659,CDM,960,RC,45379,HCPCS,OUTPATIENT,,,475,285,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,624.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,223.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8222.94,9874,
45381 PROF COLONOSCOPY SUBMUCOS,9699661,CDM,960,RC,45381,HCPCS,OUTPATIENT,,,724,434.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,601.46,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,188.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8223.94,9875,
31603 PROF TRACHEOSTOMY EMR TRNS,9699679,CDM,960,RC,31603,HCPCS,OUTPATIENT,,,674,404.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,513.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,304.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8224.94,9876,
32551 PROF INSERTION OF CHEST TUB,9699687,CDM,960,RC,32551,HCPCS,OUTPATIENT,,,535,321,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,250.73,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,147.47,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8225.94,9877,
11641 PROF EXC MILES F/E/,9699703,CDM,960,RC,11641,HCPCS,OUTPATIENT,,,450,270,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,256.79,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,145.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8226.94,9878,
44960 PROF APPY FOR RUPT APPENDI,9699711,CDM,960,RC,44960,HCPCS,OUTPATIENT,,,2500,1500,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1410.5,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,835.86,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8227.94,9879,
19300 PROF REMOVAL OF BREAST TIS,9699737,CDM,960,RC,19300,HCPCS,OUTPATIENT,,,1120,672,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,588.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,406.26,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8228.94,9880,
19301 MASTECTOMY PARTIAL,9699738,CDM,960,RC,19301,HCPCS,OUTPATIENT,,,1688,1012.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,751.54,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,628.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8229.94,9881,
11056 PROF BENIGN HYPERKERATOTIC,9699745,CDM,960,RC,11056,HCPCS,OUTPATIENT,,,85,51,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8230.94,9882,
11056 Paring or Cutting of Benign Hyperkeratotic Lesion (eg.,9699745,CDM,983,RC,11056,HCPCS,OUTPATIENT,,,168,100.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,70.68,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,21.1,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8231.94,9883,
11055 PROF PARE BENIGN,9699752,CDM,960,RC,11055,HCPCS,OUTPATIENT,,,60,36,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,58.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,14.92,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8232.94,9884,
27327 PROF EXC THIGH/KNEE LES S,9699760,CDM,960,RC,27327,HCPCS,OUTPATIENT,,,820,492,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,709.53,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,299.16,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8233.94,9885,
15120 PROF SKIN SPLT A GRAF,9699778,CDM,960,RC,15120,HCPCS,OUTPATIENT,,,2300,1380,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,937.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,650.75,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8234.94,9886,
44955 PROF APPY DONE FOR INDICAT,9699794,CDM,960,RC,44955,HCPCS,OUTPATIENT,,,350,210,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,136.97,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,79.32,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8235.94,9887,
46270 PROF SURG TX ANAL FIST S,9699802,CDM,960,RC,46270,HCPCS,OUTPATIENT,,,1205,723,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,782.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,377.33,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8236.94,9888,
54600 PROF REDUCE TORSN TESTIS SUR,9699810,CDM,960,RC,54600,HCPCS,OUTPATIENT,,,1310,786,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,803.62,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,431.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8237.94,9889,
19307 PROF MASTECTOMY MOD RA,9699828,CDM,960,RC,19307,HCPCS,OUTPATIENT,,,3476,2085.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1376.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1120.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8238.94,9890,
54150 PROF CIRCUMCISE CLAMP RINGBL,9699836,CDM,960,RC,54150,HCPCS,OUTPATIENT,,,460,276,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,265.34,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,91.48,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8239.94,9891,
49500 PROF REPAIR INIT ING HERNI,9699844,CDM,960,RC,49500,HCPCS,OUTPATIENT,,,1112,667.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,637.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,396.18,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8240.94,9892,
43233 PROF Egd balloon dil esoph30 mm/>,9699849,CDM,960,RC,43233,HCPCS,OUTPATIENT,,,700,420,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,367.3,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,215.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8241.94,9893,
27632 Exc leg/ankle les sc 3 cm/>,9699850,CDM,960,RC,27632,HCPCS,OUTPATIENT,,,1250,750,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,649.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,388.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8242.94,9894,
54640 PROF ORCHIOPEXY ING APP W/W,9699851,CDM,960,RC,54640,HCPCS,OUTPATIENT,,,1400,840,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,848.02,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,411.11,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8243.94,9895,
27634 Exc leg/ankle tum dep 5 cm/>,9699852,CDM,960,RC,27634,HCPCS,OUTPATIENT,,,2040,1224,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1066.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,639.72,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8244.94,9896,
54300 PENIS STRAIGHTENING CHORDEE,9699854,CDM,960,RC,54300,HCPCS,OUTPATIENT,,,1970,1182,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1147.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,613.09,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8245.94,9897,
17111 PROF DESTRUCTION BN LES 15,9699869,CDM,960,RC,17111,HCPCS,OUTPATIENT,,,265,159,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,138.89,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,77.6,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8246.94,9898,
43848 PROF REVISION OPN GAST BYPAS,9699877,CDM,960,RC,43848,HCPCS,OUTPATIENT,,,5805,3483,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3110.31,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1845.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8247.94,9899,
54060 EXCISION OF PENIS LESION(S),9699891,CDM,960,RC,54060,HCPCS,OUTPATIENT,,,847,508.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,314.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8248.94,9900,
19125 PROF EXC BREAST LES OPN SG,9699893,CDM,960,RC,19125,HCPCS,OUTPATIENT,,,1390,834,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,617.78,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,439.71,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8249.94,9901,
38900 PROF INTRAOP MAP LYMPHND DY,9699901,CDM,960,RC,38900,HCPCS,OUTPATIENT,,,415,249,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,245.96,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,130.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8250.94,9902,
50431 NJX PX NFROSGRM /URTRGRM,9699905,CDM,960,RC,50431,HCPCS,OUTPATIENT,,,207,124.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,337.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,61.73,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8251.94,9903,
44205 LAP COLECTOMY PART W/ILEUM,9699910,CDM,960,RC,44205,HCPCS,OUTPATIENT,,,4145,2487,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2148.32,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1264.41,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8252.94,9904,
32554 PROF THORACENTESIS NED/ASP/W,9699919,CDM,960,RC,32554,HCPCS,OUTPATIENT,,,370,222,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,310.57,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,84.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8253.94,9905,
46615 Anoscopy,9699925,CDM,960,RC,46615,HCPCS,OUTPATIENT,,,560,336,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,228.52,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,85.74,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8254.94,9906,
23075 PROF EXC TUMOR SFT SHOULDER<,9699927,CDM,960,RC,23075,HCPCS,OUTPATIENT,,,917,550.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,730.98,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,312.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8255.94,9907,
19126 PROF EXCISION ADDL BREAST LESION,9699930,CDM,960,RC,19126,HCPCS,OUTPATIENT,,,506,303.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,189.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,152.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8256.94,9908,
46280 REMOVE ANAL FIST COMPLEX,9699932,CDM,960,RC,46280,HCPCS,OUTPATIENT,,,1874,1124.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,736.72,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,453.19,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8257.94,9909,
G0105 COLOREC CANCR SCR; COLNSCPY HI RISK,9699939,CDM,960,RC,G0105,HCPCS,OUTPATIENT,,,784,470.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,514.64,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,173.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8258.94,9910,
52000 CYSTOURETHROSCOPY PF,9699941,CDM,982,RC,52000,HCPCS,OUTPATIENT,,,568,340.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,306.75,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,76.15,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8259.94,9911,
REPAIR OF CIRCUMCISION,9699942,CDM,982,RC,54163,HCPCS,OUTPATIENT,,,675,405,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,384.13,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,207.62,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8260.94,9912,
EXC FACE TUM DEEP 2 CM/,9699945,CDM,960,RC,21014,HCPCS,OUTPATIENT,,,1612,967.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,811.56,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,493.12,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8261.94,9913,
Conversion Charges:987 - REPOSITION VENOUS CATHETER PROF,9699950,CDM,987,RC,36597,HCPCS,OUTPATIENT,,,255,153,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,211.4,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,56.64,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8262.94,9914,
51102 ASP BLADDER W/TUBE INSERT,9699952,CDM,960,RC,51102,HCPCS,OUTPATIENT,,,645,387,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,382.7,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,134.93,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8263.94,9915,
52281 CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,9699963,CDM,982,RC,52281,HCPCS,OUTPATIENT,,,755,453,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,488.51,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,143.39,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8264.94,9916,
52287 PF CYSTOSCOPY CHEMODENERVATION,9699968,CDM,982,RC,52287,HCPCS,OUTPATIENT,,,485,291,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,553.45,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,159.65,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8265.94,9917,
CYSTOURETERO W/LITHOTRIPSY,9699974,CDM,982,RC,52353,HCPCS,OUTPATIENT,,,1197,718.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,683.86,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,369.57,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8266.94,9918,
49900 PROF 2ND SUTURE ABD WAL,9699976,CDM,960,RC,49900,HCPCS,OUTPATIENT,,,2381,1428.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,1298.81,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,782.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8267.94,9919,
45330 PROF SIGMOIDOSCOPY FLEX D,9699984,CDM,960,RC,45330,HCPCS,OUTPATIENT,,,186,111.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,249.19,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,53.07,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8268.94,9920,
52310 CYSTO W/REM OF FB/STENT SIMPLE PF,9699985,CDM,982,RC,52310,HCPCS,OUTPATIENT,,,704,422.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,442.94,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,143.06,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8269.94,9921,
21550 BIOPSY OF NECK/CHEST,9699989,CDM,960,RC,21550,HCPCS,OUTPATIENT,,,489,293.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,388.35,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,146.67,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8270.94,9922,
55041 REMOVAL OF HYDROCELES,9699990,CDM,960,RC,55041,HCPCS,OUTPATIENT,,,1573,943.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,906.41,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,486.84,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8271.94,9923,
INSJ NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,9800001,CDM,361,RC,11981,HCPCS,OUTPATIENT,,,218,130.8,,185.3,85,,148.24,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,76.63,35.15,,,fee schedule,35.15% of LA custom fee schedule,69.65,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,69.65,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,8272.94,9924,
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,9800002,CDM,361,RC,11982,HCPCS,OUTPATIENT,,,728,436.8,,618.8,85,,495.04,Percent of total billed charges,85% of total billed charges,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,153.62,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,255.89,35.15,,,fee schedule,35.15% of LA custom fee schedule,232.6,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,232.6,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,8273.94,9925,
COLPOSCOPY OF VULVA,9800020,CDM,361,RC,56820,HCPCS,OUTPATIENT,,,332,199.2,,282.2,85,,225.76,Percent of total billed charges,85% of total billed charges,315.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,315.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,,fee schedule,35.15% of LA custom fee schedule,106.07,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,106.07,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,8274.94,9926,
COLPOSCOPY OF VULVA W/BIOPSY,9800021,CDM,361,RC,56821,HCPCS,OUTPATIENT,,,541,324.6,,459.85,85,,367.88,Percent of total billed charges,85% of total billed charges,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,172.85,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,172.85,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,216.4,40,,173.12,percent of total billed charges,40% of total billed charges,8275.94,9927,
COLPOSCOPY OF ENTIRE VAGINA,9800040,CDM,361,RC,57420,HCPCS,OUTPATIENT,,,541,324.6,,459.85,85,,367.88,Percent of total billed charges,85% of total billed charges,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,172.85,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,172.85,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,216.4,40,,173.12,percent of total billed charges,40% of total billed charges,8276.94,9928,
COLPOSCOPY ENTIRE VAGINA W/BIOPSY,9800041,CDM,361,RC,57421,HCPCS,OUTPATIENT,,,1276.92,766.152,,1085.38,85,,868.304,Percent of total billed charges,85% of total billed charges,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,407.98,31.95,,326.384,percent of total billed charges,31.95% of total billed charges,407.98,31.95,,326.384,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,500,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,510.77,40,,408.616,percent of total billed charges,40% of total billed charges,8277.94,9929,
DILATION CERVICAL CANAL INSTRUMENTAL,9800060,CDM,361,RC,57800,HCPCS,OUTPATIENT,,,4996.2,2997.72,,4246.77,85,,3397.416,Percent of total billed charges,85% of total billed charges,3664.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,3664.65,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,1596.29,31.95,,1277.032,percent of total billed charges,31.95% of total billed charges,1596.29,31.95,,1277.032,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,1450,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,1998.48,40,,1598.784,percent of total billed charges,40% of total billed charges,8278.94,9930,
ENDOMETRIAL  BIOPSY,9800080,CDM,361,RC,58100,HCPCS,OUTPATIENT,,,332,199.2,,282.2,85,,225.76,Percent of total billed charges,85% of total billed charges,315.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,315.79,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,116.7,35.15,,,fee schedule,35.15% of LA custom fee schedule,106.07,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,106.07,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,8279.94,9931,
INSERTION INTRAUTERINE DEVICE IUD,9800090,CDM,361,RC,58300,HCPCS,OUTPATIENT,,,375,225,,318.75,85,,255,Percent of total billed charges,85% of total billed charges,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,119.81,31.95,,95.848,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,150,40,,120,percent of total billed charges,40% of total billed charges,8280.94,9932,
REMOVAL INTRAUTERINE DEVICE IUD,9800091,CDM,361,RC,58301,HCPCS,OUTPATIENT,,,541,324.6,,459.85,85,,367.88,Percent of total billed charges,85% of total billed charges,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,595.96,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,172.85,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,172.85,31.95,,138.28,percent of total billed charges,31.95% of total billed charges,,,,,other,Not separately reimbursable,385,100,,,Fee Schedule,100% of Asc Tier Grouping Fee Schedule,216.4,40,,173.12,percent of total billed charges,40% of total billed charges,8281.94,9933,
11981 INSJ NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,9800201,CDM,988,RC,11981,HCPCS,OUTPATIENT,,,134,80.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,155.03,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,59.68,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8282.94,9934,
11982 REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,9800202,CDM,988,RC,11982,HCPCS,OUTPATIENT,,,157,94.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,172.65,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,69.61,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8283.94,9935,
56820 COLPOSCOPY OF VULVA,9800220,CDM,988,RC,56820,HCPCS,OUTPATIENT,,,176,105.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,179.58,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,80.21,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8284.94,9936,
56821 COLPOSCOPY OF VULVA W/BIOPSY,9800221,CDM,988,RC,56821,HCPCS,OUTPATIENT,,,236,141.6,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,238.74,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,108.37,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8285.94,9937,
57420 COLPOSCOPY OF ENTIRE VAGINA,9800240,CDM,988,RC,57420,HCPCS,OUTPATIENT,,,187,112.2,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,189.16,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,85.63,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8286.94,9938,
57421 COLPOSCOPY ENTIRE VAGINA W/BIOPSY,9800241,CDM,988,RC,57421,HCPCS,OUTPATIENT,,,254,152.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,253.37,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,116.35,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8287.94,9939,
57800 DILATION CERVICAL CANAL INSTRUMENTAL,9800260,CDM,988,RC,57800,HCPCS,OUTPATIENT,,,98,58.8,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,100.17,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,45.77,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8288.94,9940,
58100 ENDOMETRIAL  BIOPSY,9800280,CDM,988,RC,58100,HCPCS,OUTPATIENT,,,134,80.4,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,143.8,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,60.53,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8289.94,9941,
58300 INSERTION INTRAUTERINE DEVICE IUD,9800290,CDM,988,RC,58300,HCPCS,OUTPATIENT,,,175,105,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,124.14,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,48.14,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8290.94,9942,
58301 REMOVAL INTRAUTERINE DEVICE IUD,9800291,CDM,988,RC,58301,HCPCS,OUTPATIENT,,,140,84,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,147.21,100,,,fee schedule,100% of BCBS custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,63.42,100,,,fee schedule,100% of CMS physician fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,8291.94,9943,
BCG (INTRAVESICAL) PER INSTILLATION,22550937,CDM,521,RC,J9030,HCPCS,OUTPATIENT,,,600,360,,510,85,,408,Percent of total billed charges,85% of total billed charges,4.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,4.38,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,191.7,31.95,,153.36,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,228,38,,182.4,percent of total billed charges,38% of total billed charges,240,40,,192,percent of total billed charges,40% of total billed charges,8292.94,9944,
VFC - Flu Vaccine 6 through 35 months-0.25 mL(single-dose),22558414,CDM,636,RC,90685,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,29.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,29.56,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,,fee schedule,35.15% of LA custom fee schedule,3.02,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,3.02,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,8293.94,9945,
VFC - Flu Vaccine 3 years  older-0.5 mL(single-dose),22558415,CDM,250,RC,90686,HCPCS,OUTPATIENT,,,9.45,5.67,,8.03,85,,6.424,Percent of total billed charges,85% of total billed charges,30.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,30.53,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,3.32,35.15,,,fee schedule,35.15% of LA custom fee schedule,3.02,31.95,,,fee schedule,31.95% of LA custom fee schedule,,,,,other,Not separately reimbursable,3.59,38,,2.872,percent of total billed charges,38% of total billed charges,3.02,31.95,,,Fee Schedule,31.95% of LA custom fee schedule,8294.94,9946,
Priv Ins - Flu Vaccine 6 through 35 months-5.0 mL(multi-dose,22558417,CDM,521,RC,90687,HCPCS,OUTPATIENT,,,20,12,,17,85,,13.6,Percent of total billed charges,85% of total billed charges,14.26,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,,,,,other ,Not separately reimbursable,14.26,136.6,,,fee schedule,136.60% of BCBS custom fee schedule,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,6.39,31.95,,5.112,percent of total billed charges,31.95% of total billed charges,160.45,100,,,case rate,pays based on per visit rate,7.6,38,,6.08,percent of total billed charges,38% of total billed charges,8,40,,6.4,percent of total billed charges,40% of total billed charges,8295.94,9947,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,347956.06,100,MS DRG,278364.85,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8296.94,9948,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,138747.58,100,MS DRG,110998.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8297.94,9949,
"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,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,265770.06,100,MS DRG,212616.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8298.94,9950,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,176692.43,100,MS DRG,141353.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8299.94,9951,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,134230.01,100,MS DRG,107384.01,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8300.94,9952,
LIVER TRANSPLANT WITHOUT MCC,6,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,63469.08,100,MS DRG,50775.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8301.94,9953,
LUNG TRANSPLANT,7,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,163746.07,100,MS DRG,130996.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8302.94,9954,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,70690.11,100,MS DRG,56552.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8303.94,9955,
PANCREAS TRANSPLANT,10,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,101578.64,100,MS DRG,81262.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8304.94,9956,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,70138.68,100,MS DRG,56110.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8305.94,9957,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,54374.17,100,MS DRG,43499.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8306.94,9958,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36639.4,100,MS DRG,29311.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8307.94,9959,
ALLOGENEIC BONE MARROW TRANSPLANT,14,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,164148.66,100,MS DRG,131318.93,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8308.94,9960,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,77946.51,100,MS DRG,62357.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8309.94,9961,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,77946.51,100,MS DRG,62357.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8310.94,9962,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,464396.51,100,MS DRG,371517.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8311.94,9963,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,101021.1,100,MS DRG,80816.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8312.94,9964,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,102653.43,100,MS DRG,82122.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8313.94,9965,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,71741.72,100,MS DRG,57393.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8314.94,9966,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47380.05,100,MS DRG,37904.04,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8315.94,9967,
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,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,73910.84,100,MS DRG,59128.67,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8316.94,9968,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,50689.84,100,MS DRG,40551.87,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8317.94,9969,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,58870.99,100,MS DRG,47096.79,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8318.94,9970,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,41624.22,100,MS DRG,33299.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8319.94,9971,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,34416.61,100,MS DRG,27533.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8320.94,9972,
SPINAL PROCEDURES WITH MCC,28,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,78478.42,100,MS DRG,62782.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8321.94,9973,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,45260.96,100,MS DRG,36208.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8322.94,9974,
SPINAL PROCEDURES WITHOUT CC/MCC,30,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31459.4,100,MS DRG,25167.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8323.94,9975,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,55434.33,100,MS DRG,44347.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8324.94,9976,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30363.86,100,MS DRG,24291.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8325.94,9977,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23774.78,100,MS DRG,19019.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8326.94,9978,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,51751.23,100,MS DRG,41400.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8327.94,9979,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32062.06,100,MS DRG,25649.65,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8328.94,9980,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26673.43,100,MS DRG,21338.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8329.94,9981,
EXTRACRANIAL PROCEDURES WITH MCC,37,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,44824.21,100,MS DRG,35859.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8330.94,9982,
EXTRACRANIAL PROCEDURES WITH CC,38,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23967.53,100,MS DRG,19174.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8331.94,9983,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18195.84,100,MS DRG,14556.67,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8332.94,9984,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,50328.73,100,MS DRG,40262.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8333.94,9985,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31859.54,100,MS DRG,25487.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8334.94,9986,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25752.36,100,MS DRG,20601.89,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8335.94,9987,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28862.07,100,MS DRG,23089.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8336.94,9988,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15550.94,100,MS DRG,12440.75,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8337.94,9989,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22598.72,100,MS DRG,18078.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8338.94,9990,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17620.01,100,MS DRG,14096.01,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8339.94,9991,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,34859.47,100,MS DRG,27887.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8340.94,9992,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20589.43,100,MS DRG,16471.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8341.94,9993,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26829.59,100,MS DRG,21463.67,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8342.94,9994,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19237.7,100,MS DRG,15390.16,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8343.94,9995,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15197.14,100,MS DRG,12157.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8344.94,9996,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37290.87,100,MS DRG,29832.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8345.94,9997,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26036.62,100,MS DRG,20829.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8346.94,9998,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21448.29,100,MS DRG,17158.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8347.94,9999,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28577.82,100,MS DRG,22862.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8348.94,10000,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16716,100,MS DRG,13372.8,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8349.94,10001,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12707.17,100,MS DRG,10165.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8350.94,10002,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22059.5,100,MS DRG,17647.6,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8351.94,10003,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15064.16,100,MS DRG,12051.33,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8352.94,10004,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14071.11,100,MS DRG,11256.89,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8353.94,10005,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25523.01,100,MS DRG,20418.41,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8354.94,10006,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17167.4,100,MS DRG,13733.92,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8355.94,10007,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13462.34,100,MS DRG,10769.87,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8356.94,10008,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23166.01,100,MS DRG,18532.81,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8357.94,10009,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17027.1,100,MS DRG,13621.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8358.94,10010,
VIRAL MENINGITIS WITH CC/MCC,75,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25322.93,100,MS DRG,20258.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8359.94,10011,
VIRAL MENINGITIS WITHOUT CC/MCC,76,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15496.04,100,MS DRG,12396.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8360.94,10012,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23174.54,100,MS DRG,18539.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8361.94,10013,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16484.22,100,MS DRG,13187.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8362.94,10014,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12443.66,100,MS DRG,9954.93,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8363.94,10015,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28560.74,100,MS DRG,22848.59,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8364.94,10016,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15348.42,100,MS DRG,12278.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8365.94,10017,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32615.93,100,MS DRG,26092.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8366.94,10018,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21272.62,100,MS DRG,17018.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8367.94,10019,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15974.26,100,MS DRG,12779.41,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8368.94,10020,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31954.7,100,MS DRG,25563.76,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8369.94,10021,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20311.28,100,MS DRG,16249.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8370.94,10022,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15094.66,100,MS DRG,12075.73,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8371.94,10023,
CONCUSSION WITH MCC,88,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21520.26,100,MS DRG,17216.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8372.94,10024,
CONCUSSION WITH CC,89,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17389.43,100,MS DRG,13911.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8373.94,10025,
CONCUSSION WITHOUT CC/MCC,90,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14768.93,100,MS DRG,11815.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8374.94,10026,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26549,100,MS DRG,21239.2,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8375.94,10027,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17225.96,100,MS DRG,13780.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8376.94,10028,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13939.35,100,MS DRG,11151.48,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8377.94,10029,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,48823.28,100,MS DRG,39058.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8378.94,10030,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33555.3,100,MS DRG,26844.24,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8379.94,10031,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33555.3,100,MS DRG,26844.24,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8380.94,10032,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,48041.29,100,MS DRG,38433.03,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8381.94,10033,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30774.99,100,MS DRG,24619.99,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8382.94,10034,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21307.99,100,MS DRG,17046.39,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8383.94,10035,
SEIZURES WITH MCC,100,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28530.23,100,MS DRG,22824.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8384.94,10036,
SEIZURES WITHOUT MCC,101,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15554.6,100,MS DRG,12443.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8385.94,10037,
HEADACHES WITH MCC,102,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18455.68,100,MS DRG,14764.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8386.94,10038,
HEADACHES WITHOUT MCC,103,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14682.31,100,MS DRG,11745.85,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8387.94,10039,
ORBITAL PROCEDURES WITH CC/MCC,113,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31840.02,100,MS DRG,25472.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8388.94,10040,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18731.4,100,MS DRG,14985.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8389.94,10041,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22987.9,100,MS DRG,18390.32,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8390.94,10042,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24666.57,100,MS DRG,19733.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8391.94,10043,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17468.73,100,MS DRG,13974.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8392.94,10044,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18500.82,100,MS DRG,14800.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8393.94,10045,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12585.18,100,MS DRG,10068.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8394.94,10046,
NEUROLOGICAL EYE DISORDERS,123,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14108.92,100,MS DRG,11287.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8395.94,10047,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20217.33,100,MS DRG,16173.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8396.94,10048,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14383.41,100,MS DRG,11506.73,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8397.94,10049,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33724.89,100,MS DRG,26979.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8398.94,10050,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16243.87,100,MS DRG,12995.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8399.94,10051,
MOUTH PROCEDURES WITH CC/MCC,137,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21372.64,100,MS DRG,17098.11,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8400.94,10052,
MOUTH PROCEDURES WITHOUT CC/MCC,138,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14234.57,100,MS DRG,11387.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8401.94,10053,
SALIVARY GLAND PROCEDURES,139,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21060.34,100,MS DRG,16848.27,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8402.94,10054,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,55905.23,100,MS DRG,44724.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8403.94,10055,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30521.22,100,MS DRG,24416.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8404.94,10056,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23492.97,100,MS DRG,18794.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8405.94,10057,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,44592.42,100,MS DRG,35673.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8406.94,10058,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25741.37,100,MS DRG,20593.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8407.94,10059,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18764.34,100,MS DRG,15011.47,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8408.94,10060,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32297.51,100,MS DRG,25838.01,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8409.94,10061,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19496.32,100,MS DRG,15597.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8410.94,10062,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14078.43,100,MS DRG,11262.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8411.94,10063,
DYSEQUILIBRIUM,149,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13429.4,100,MS DRG,10743.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8412.94,10064,
EPISTAXIS WITH MCC,150,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21172.58,100,MS DRG,16938.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8413.94,10065,
EPISTAXIS WITHOUT MCC,151,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13557.49,100,MS DRG,10845.99,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8414.94,10066,
OTITIS MEDIA AND URI WITH MCC,152,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18154.37,100,MS DRG,14523.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8415.94,10067,
OTITIS MEDIA AND URI WITHOUT MCC,153,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12992.64,100,MS DRG,10394.11,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8416.94,10068,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24150.53,100,MS DRG,19320.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8417.94,10069,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15699.77,100,MS DRG,12559.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8418.94,10070,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12513.2,100,MS DRG,10010.56,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8419.94,10071,
DENTAL AND ORAL DISEASES WITH MCC,157,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24287.17,100,MS DRG,19429.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8420.94,10072,
DENTAL AND ORAL DISEASES WITH CC,158,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15785.17,100,MS DRG,12628.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8421.94,10073,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12357.03,100,MS DRG,9885.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8422.94,10074,
MAJOR CHEST PROCEDURES WITH MCC,163,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,60541.14,100,MS DRG,48432.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8423.94,10075,
MAJOR CHEST PROCEDURES WITH CC,164,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35016.83,100,MS DRG,28013.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8424.94,10076,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27050.4,100,MS DRG,21640.32,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8425.94,10077,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,51282.76,100,MS DRG,41026.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8426.94,10078,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26601.46,100,MS DRG,21281.17,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8427.94,10079,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20827.33,100,MS DRG,16661.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8428.94,10080,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,41746.22,100,MS DRG,33396.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8429.94,10081,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21500.74,100,MS DRG,17200.59,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8430.94,10082,
PULMONARY EMBOLISM WITHOUT MCC,176,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14246.78,100,MS DRG,11397.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8431.94,10083,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24030.97,100,MS DRG,19224.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8432.94,10084,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16413.45,100,MS DRG,13130.76,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8433.94,10085,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13700.23,100,MS DRG,10960.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8434.94,10086,
RESPIRATORY NEOPLASMS WITH MCC,180,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25632.8,100,MS DRG,20506.24,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8435.94,10087,
RESPIRATORY NEOPLASMS WITH CC,181,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17855.46,100,MS DRG,14284.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8436.94,10088,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14527.37,100,MS DRG,11621.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8437.94,10089,
MAJOR CHEST TRAUMA WITH MCC,183,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23674.74,100,MS DRG,18939.79,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8438.94,10090,
MAJOR CHEST TRAUMA WITH CC,184,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17340.63,100,MS DRG,13872.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8439.94,10091,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13797.82,100,MS DRG,11038.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8440.94,10092,
PLEURAL EFFUSION WITH MCC,186,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23585.69,100,MS DRG,18868.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8441.94,10093,
PLEURAL EFFUSION WITH CC,187,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16558.63,100,MS DRG,13246.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8442.94,10094,
PLEURAL EFFUSION WITHOUT CC/MCC,188,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13267.14,100,MS DRG,10613.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8443.94,10095,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19406.05,100,MS DRG,15524.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8444.94,10096,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18010.4,100,MS DRG,14408.32,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8445.94,10097,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14790.89,100,MS DRG,11832.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8446.94,10098,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12205.75,100,MS DRG,9764.6,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8447.94,10099,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20385.69,100,MS DRG,16308.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8448.94,10100,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14313.87,100,MS DRG,11451.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8449.94,10101,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11906.87,100,MS DRG,9525.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8450.94,10102,
INTERSTITIAL LUNG DISEASE WITH MCC,196,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27295.61,100,MS DRG,21836.49,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8451.94,10103,
INTERSTITIAL LUNG DISEASE WITH CC,197,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16387.84,100,MS DRG,13110.27,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8452.94,10104,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12854.79,100,MS DRG,10283.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8453.94,10105,
PNEUMOTHORAX WITH MCC,199,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25846.29,100,MS DRG,20677.03,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8454.94,10106,
PNEUMOTHORAX WITH CC,200,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17821.31,100,MS DRG,14257.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8455.94,10107,
PNEUMOTHORAX WITHOUT CC/MCC,201,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12570.54,100,MS DRG,10056.43,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8456.94,10108,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16103.58,100,MS DRG,12882.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8457.94,10109,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12808.43,100,MS DRG,10246.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8458.94,10110,
RESPIRATORY SIGNS AND SYMPTOMS,204,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14204.08,100,MS DRG,11363.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8459.94,10111,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27340.76,100,MS DRG,21872.61,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8460.94,10112,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15360.62,100,MS DRG,12288.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8461.94,10113,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,83208.25,100,MS DRG,66566.6,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8462.94,10114,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37051.76,100,MS DRG,29641.41,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8463.94,10115,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,137212.86,100,MS DRG,109770.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8464.94,10116,
OTHER HEART ASSIST SYSTEM IMPLANT,215,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,133563.91,100,MS DRG,106851.13,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8465.94,10117,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,122051.02,100,MS DRG,97640.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8466.94,10118,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,83094.8,100,MS DRG,66475.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8467.94,10119,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,76890.02,100,MS DRG,61512.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8468.94,10120,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,98705.6,100,MS DRG,78964.48,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8469.94,10121,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,68928.46,100,MS DRG,55142.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8470.94,10122,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,60338.62,100,MS DRG,48270.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8471.94,10123,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,65105.06,100,MS DRG,52084.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8472.94,10124,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,42206.15,100,MS DRG,33764.92,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8473.94,10125,
CORONARY BYPASS WITH PTCA WITH MCC,231,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,107689.47,100,MS DRG,86151.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8474.94,10126,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,78834.65,100,MS DRG,63067.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8475.94,10127,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,99668.15,100,MS DRG,79734.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8476.94,10128,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,69215.17,100,MS DRG,55372.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8477.94,10129,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,76095.8,100,MS DRG,60876.64,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8478.94,10130,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,54476.64,100,MS DRG,43581.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8479.94,10131,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,65758.97,100,MS DRG,52607.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8480.94,10132,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39838.17,100,MS DRG,31870.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8481.94,10133,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22730.48,100,MS DRG,18184.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8482.94,10134,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,45691.61,100,MS DRG,36553.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8483.94,10135,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31793.67,100,MS DRG,25434.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8484.94,10136,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26326.97,100,MS DRG,21061.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8485.94,10137,
AICD GENERATOR PROCEDURES,245,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,63927.78,100,MS DRG,51142.22,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8486.94,10138,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32523.21,100,MS DRG,26018.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8487.94,10139,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23373.4,100,MS DRG,18698.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8488.94,10140,
OTHER VASCULAR PROCEDURES WITH MCC,252,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46160.09,100,MS DRG,36928.07,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8489.94,10141,
OTHER VASCULAR PROCEDURES WITH CC,253,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35456.03,100,MS DRG,28364.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8490.94,10142,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25652.33,100,MS DRG,20521.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8491.94,10143,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36230.72,100,MS DRG,28984.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8492.94,10144,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24972.78,100,MS DRG,19978.22,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8493.94,10145,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15191.03,100,MS DRG,12152.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8494.94,10146,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,38536.46,100,MS DRG,30829.17,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8495.94,10147,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25753.58,100,MS DRG,20602.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8496.94,10148,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,45864.85,100,MS DRG,36691.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8497.94,10149,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27460.32,100,MS DRG,21968.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8498.94,10150,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22826.87,100,MS DRG,18261.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8499.94,10151,
VEIN LIGATION AND STRIPPING,263,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37031.01,100,MS DRG,29624.81,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8500.94,10152,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46949.4,100,MS DRG,37559.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8501.94,10153,
AICD LEAD PROCEDURES,265,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47829.01,100,MS DRG,38263.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8502.94,10154,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,77396.3,100,MS DRG,61917.04,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8503.94,10155,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,61706.21,100,MS DRG,49364.97,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8504.94,10156,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,85653.09,100,MS DRG,68522.47,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8505.94,10157,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,55069.54,100,MS DRG,44055.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8506.94,10158,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,66931.36,100,MS DRG,53545.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8507.94,10159,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46330.88,100,MS DRG,37064.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8508.94,10160,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,34836.29,100,MS DRG,27869.03,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8509.94,10161,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,52014.74,100,MS DRG,41611.79,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8510.94,10162,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,42385.48,100,MS DRG,33908.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8511.94,10163,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,90525.66,100,MS DRG,72420.53,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8512.94,10164,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC OR CAROTID SINUS NEUROSTIMULATOR,276,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,79880.16,100,MS DRG,63904.13,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8513.94,10165,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,61062.06,100,MS DRG,48849.65,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8514.94,10166,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,65349.06,100,MS DRG,52279.25,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8515.94,10167,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,43402.94,100,MS DRG,34722.35,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8516.94,10168,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24334.75,100,MS DRG,19467.8,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8517.94,10169,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15555.81,100,MS DRG,12444.65,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8518.94,10170,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13156.12,100,MS DRG,10524.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8519.94,10171,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28165.47,100,MS DRG,22532.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8520.94,10172,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13350.1,100,MS DRG,10680.08,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8521.94,10173,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11159.03,100,MS DRG,8927.22,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8522.94,10174,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31311.79,100,MS DRG,25049.43,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8523.94,10175,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17604.15,100,MS DRG,14083.32,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8524.94,10176,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37633.69,100,MS DRG,30106.95,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8525.94,10177,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23545.42,100,MS DRG,18836.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8526.94,10178,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16253.64,100,MS DRG,13002.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8527.94,10179,
HEART FAILURE AND SHOCK WITH MCC,291,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20228.32,100,MS DRG,16182.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8528.94,10180,
HEART FAILURE AND SHOCK WITH CC,292,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14816.5,100,MS DRG,11853.2,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8529.94,10181,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11004.09,100,MS DRG,8803.27,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8530.94,10182,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19291.37,100,MS DRG,15433.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8531.94,10183,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13945.45,100,MS DRG,11156.36,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8532.94,10184,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24298.15,100,MS DRG,19438.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8533.94,10185,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12903.59,100,MS DRG,10322.87,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8534.94,10186,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,9698.72,100,MS DRG,7758.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8535.94,10187,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24044.4,100,MS DRG,19235.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8536.94,10188,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17371.14,100,MS DRG,13896.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8537.94,10189,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13013.4,100,MS DRG,10410.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8538.94,10190,
ATHEROSCLEROSIS WITH MCC,302,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18502.05,100,MS DRG,14801.64,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8539.94,10191,
ATHEROSCLEROSIS WITHOUT MCC,303,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12513.2,100,MS DRG,10010.56,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8540.94,10192,
HYPERTENSION WITH MCC,304,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18642.35,100,MS DRG,14913.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8541.94,10193,
HYPERTENSION WITHOUT MCC,305,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13468.44,100,MS DRG,10774.75,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8542.94,10194,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22577.98,100,MS DRG,18062.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8543.94,10195,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15611.93,100,MS DRG,12489.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8544.94,10196,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19021.75,100,MS DRG,15217.4,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8545.94,10197,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13329.37,100,MS DRG,10663.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8546.94,10198,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11135.85,100,MS DRG,8908.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8547.94,10199,
ANGINA PECTORIS,311,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12829.18,100,MS DRG,10263.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8548.94,10200,
SYNCOPE AND COLLAPSE,312,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14939.72,100,MS DRG,11951.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8549.94,10201,
CHEST PAIN,313,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13013.4,100,MS DRG,10410.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8550.94,10202,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30582.23,100,MS DRG,24465.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8551.94,10203,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16049.89,100,MS DRG,12839.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8552.94,10204,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12638.86,100,MS DRG,10111.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8553.94,10205,
CONCOMITANT LEFT ATRIAL APPENDAGE CLOSURE AND CARDIAC ABLATION,317,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,79782.56,100,MS DRG,63826.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8554.94,10206,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,57901.12,100,MS DRG,46320.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8555.94,10207,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32550.05,100,MS DRG,26040.04,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8556.94,10208,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39040.31,100,MS DRG,31232.25,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8557.94,10209,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26381.87,100,MS DRG,21105.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8558.94,10210,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,56273.67,100,MS DRG,45018.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8559.94,10211,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,43289.49,100,MS DRG,34631.59,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8560.94,10212,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39226.98,100,MS DRG,31381.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8561.94,10213,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,66272.58,100,MS DRG,53018.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8562.94,10214,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33932.28,100,MS DRG,27145.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8563.94,10215,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23750.38,100,MS DRG,19000.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8564.94,10216,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,60330.08,100,MS DRG,48264.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8565.94,10217,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33146.62,100,MS DRG,26517.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8566.94,10218,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24451.86,100,MS DRG,19561.49,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8567.94,10219,
RECTAL RESECTION WITH MCC,332,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46627.33,100,MS DRG,37301.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8568.94,10220,
RECTAL RESECTION WITH CC,333,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30238.2,100,MS DRG,24190.56,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8569.94,10221,
RECTAL RESECTION WITHOUT CC/MCC,334,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24544.58,100,MS DRG,19635.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8570.94,10222,
PERITONEAL ADHESIOLYSIS WITH MCC,335,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,48514.63,100,MS DRG,38811.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8571.94,10223,
PERITONEAL ADHESIOLYSIS WITH CC,336,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30079.61,100,MS DRG,24063.69,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8572.94,10224,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23037.91,100,MS DRG,18430.33,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8573.94,10225,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37182.3,100,MS DRG,29745.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8574.94,10226,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22471.85,100,MS DRG,17977.48,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8575.94,10227,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19502.44,100,MS DRG,15601.95,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8576.94,10228,
ANAL AND STOMAL PROCEDURES WITH MCC,347,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33184.43,100,MS DRG,26547.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8577.94,10229,
ANAL AND STOMAL PROCEDURES WITH CC,348,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19668.34,100,MS DRG,15734.67,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8578.94,10230,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15056.84,100,MS DRG,12045.47,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8579.94,10231,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33817.61,100,MS DRG,27054.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8580.94,10232,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22664.6,100,MS DRG,18131.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8581.94,10233,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17761.53,100,MS DRG,14209.22,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8582.94,10234,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,40091.94,100,MS DRG,32073.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8583.94,10235,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25063.07,100,MS DRG,20050.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8584.94,10236,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20574.79,100,MS DRG,16459.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8585.94,10237,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,56350.52,100,MS DRG,45080.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8586.94,10238,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31783.91,100,MS DRG,25427.13,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8587.94,10239,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20841.96,100,MS DRG,16673.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8588.94,10240,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24683.65,100,MS DRG,19746.92,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8589.94,10241,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16724.54,100,MS DRG,13379.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8590.94,10242,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12825.5,100,MS DRG,10260.4,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8591.94,10243,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25635.24,100,MS DRG,20508.19,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8592.94,10244,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16867.29,100,MS DRG,13493.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8593.94,10245,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13159.79,100,MS DRG,10527.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8594.94,10246,
DIGESTIVE MALIGNANCY WITH MCC,374,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30068.62,100,MS DRG,24054.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8595.94,10247,
DIGESTIVE MALIGNANCY WITH CC,375,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19299.91,100,MS DRG,15439.93,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8596.94,10248,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15082.46,100,MS DRG,12065.97,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8597.94,10249,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26491.66,100,MS DRG,21193.33,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8598.94,10250,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16337.83,100,MS DRG,13070.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8599.94,10251,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12077.67,100,MS DRG,9662.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8600.94,10252,
COMPLICATED PEPTIC ULCER WITH MCC,380,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27786.05,100,MS DRG,22228.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8601.94,10253,
COMPLICATED PEPTIC ULCER WITH CC,381,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17596.82,100,MS DRG,14077.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8602.94,10254,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13451.36,100,MS DRG,10761.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8603.94,10255,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19733,100,MS DRG,15786.4,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8604.94,10256,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14918.99,100,MS DRG,11935.19,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8605.94,10257,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24132.22,100,MS DRG,19305.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8606.94,10258,
INFLAMMATORY BOWEL DISEASE WITH CC,386,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16418.33,100,MS DRG,13134.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8607.94,10259,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12487.58,100,MS DRG,9990.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8608.94,10260,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22242.49,100,MS DRG,17793.99,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8609.94,10261,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14089.39,100,MS DRG,11271.51,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8610.94,10262,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,10985.79,100,MS DRG,8788.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8611.94,10263,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19980.65,100,MS DRG,15984.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8612.94,10264,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13829.55,100,MS DRG,11063.64,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8613.94,10265,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24512.86,100,MS DRG,19610.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8614.94,10266,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15793.71,100,MS DRG,12634.97,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8615.94,10267,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12073.99,100,MS DRG,9659.19,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8616.94,10268,
APPENDIX PROCEDURES WITH MCC,397,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,34538.61,100,MS DRG,27630.89,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8617.94,10269,
APPENDIX PROCEDURES WITH CC,398,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22770.74,100,MS DRG,18216.59,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8618.94,10270,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18020.16,100,MS DRG,14416.13,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8619.94,10271,
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL,402,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,52037.91,100,MS DRG,41630.33,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8620.94,10272,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,70538.83,100,MS DRG,56431.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8621.94,10273,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,38571.84,100,MS DRG,30857.47,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8622.94,10274,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30366.29,100,MS DRG,24293.03,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8623.94,10275,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47025.05,100,MS DRG,37620.04,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8624.94,10276,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29886.86,100,MS DRG,23909.49,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8625.94,10277,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23233.12,100,MS DRG,18586.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8626.94,10278,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37693.46,100,MS DRG,30154.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8627.94,10279,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30315.06,100,MS DRG,24252.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8628.94,10280,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24592.16,100,MS DRG,19673.73,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8629.94,10281,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47055.54,100,MS DRG,37644.43,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8630.94,10282,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28442.41,100,MS DRG,22753.93,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8631.94,10283,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21026.18,100,MS DRG,16820.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8632.94,10284,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33302.78,100,MS DRG,26642.22,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8633.94,10285,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24542.14,100,MS DRG,19633.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8634.94,10286,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20384.46,100,MS DRG,16307.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8635.94,10287,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47369.08,100,MS DRG,37895.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8636.94,10288,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24288.39,100,MS DRG,19430.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8637.94,10289,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22236.4,100,MS DRG,17789.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8638.94,10290,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,53931.32,100,MS DRG,43145.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8639.94,10291,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32165.75,100,MS DRG,25732.6,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8640.94,10292,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23168.46,100,MS DRG,18534.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8641.94,10293,
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,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,132107.26,100,MS DRG,105685.81,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8642.94,10294,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC,427,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,90961.19,100,MS DRG,72768.95,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8643.94,10295,
MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC,428,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,71458.68,100,MS DRG,57166.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8644.94,10296,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC,429,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,106063.25,100,MS DRG,84850.6,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8645.94,10297,
COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC,430,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,71048.78,100,MS DRG,56839.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8646.94,10298,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28210.61,100,MS DRG,22568.49,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8647.94,10299,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17361.38,100,MS DRG,13889.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8648.94,10300,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12807.21,100,MS DRG,10245.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8649.94,10301,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26569.74,100,MS DRG,21255.79,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8650.94,10302,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18067.74,100,MS DRG,14454.19,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8651.94,10303,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13889.32,100,MS DRG,11111.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8652.94,10304,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24606.8,100,MS DRG,19685.44,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8653.94,10305,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14804.31,100,MS DRG,11843.45,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8654.94,10306,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11814.14,100,MS DRG,9451.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8655.94,10307,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27372.48,100,MS DRG,21897.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8656.94,10308,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16097.47,100,MS DRG,12877.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8657.94,10309,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12882.85,100,MS DRG,10306.28,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8658.94,10310,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24859.33,100,MS DRG,19887.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8659.94,10311,
DISORDERS OF THE BILIARY TRACT WITH CC,445,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17540.71,100,MS DRG,14032.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8660.94,10312,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14036.94,100,MS DRG,11229.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8661.94,10313,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,447,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,86105.71,100,MS DRG,68884.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8662.94,10314,
MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,448,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,54127.72,100,MS DRG,43302.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8663.94,10315,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE,450,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,67139.98,100,MS DRG,53711.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8664.94,10316,
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,451,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,41958.5,100,MS DRG,33566.8,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8665.94,10317,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,107632.14,100,MS DRG,86105.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8666.94,10318,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,74329.28,100,MS DRG,59463.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8667.94,10319,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,56988.57,100,MS DRG,45590.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8668.94,10320,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,79176.24,100,MS DRG,63340.99,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8669.94,10321,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39247.71,100,MS DRG,31398.17,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8670.94,10322,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,70200.89,100,MS DRG,56160.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8671.94,10323,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,40282.25,100,MS DRG,32225.8,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8672.94,10324,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25490.06,100,MS DRG,20392.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8673.94,10325,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,66462.89,100,MS DRG,53170.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8674.94,10326,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46096.64,100,MS DRG,36877.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8675.94,10327,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36313.67,100,MS DRG,29050.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8676.94,10328,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,44187.38,100,MS DRG,35349.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8677.94,10329,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27312.7,100,MS DRG,21850.16,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8678.94,10330,
CERVICAL SPINAL FUSION WITH MCC,471,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,63567.89,100,MS DRG,50854.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8679.94,10331,
CERVICAL SPINAL FUSION WITH CC,472,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39655.19,100,MS DRG,31724.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8680.94,10332,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33191.77,100,MS DRG,26553.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8681.94,10333,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,59022.27,100,MS DRG,47217.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8682.94,10334,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30628.59,100,MS DRG,24502.87,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8683.94,10335,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18499.61,100,MS DRG,14799.69,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8684.94,10336,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46265,100,MS DRG,37012,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8685.94,10337,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32840.41,100,MS DRG,26272.33,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8686.94,10338,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25974.4,100,MS DRG,20779.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8687.94,10339,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,40189.53,100,MS DRG,32151.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8688.94,10340,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29623.33,100,MS DRG,23698.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8689.94,10341,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23663.75,100,MS DRG,18931,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8690.94,10342,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35397.47,100,MS DRG,28317.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8691.94,10343,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,43584.72,100,MS DRG,34867.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8692.94,10344,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30184.52,100,MS DRG,24147.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8693.94,10345,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23588.12,100,MS DRG,18870.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8694.94,10346,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28287.46,100,MS DRG,22629.97,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8695.94,10347,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19418.26,100,MS DRG,15534.61,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8696.94,10348,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47633.82,100,MS DRG,38107.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8697.94,10349,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33601.68,100,MS DRG,26881.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8698.94,10350,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27311.48,100,MS DRG,21849.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8699.94,10351,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47260.5,100,MS DRG,37808.4,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8700.94,10352,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28380.18,100,MS DRG,22704.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8701.94,10353,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20689.46,100,MS DRG,16551.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8702.94,10354,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35113.21,100,MS DRG,28090.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8703.94,10355,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18471.54,100,MS DRG,14777.23,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8704.94,10356,
SOFT TISSUE PROCEDURES WITH MCC,500,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,42967.41,100,MS DRG,34373.93,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8705.94,10357,
SOFT TISSUE PROCEDURES WITH CC,501,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26082.97,100,MS DRG,20866.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8706.94,10358,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21355.56,100,MS DRG,17084.45,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8707.94,10359,
FOOT PROCEDURES WITH MCC,503,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36597.93,100,MS DRG,29278.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8708.94,10360,
FOOT PROCEDURES WITH CC,504,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25720.64,100,MS DRG,20576.51,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8709.94,10361,
FOOT PROCEDURES WITHOUT CC/MCC,505,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25720.64,100,MS DRG,20576.51,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8710.94,10362,
MAJOR THUMB OR JOINT PROCEDURES,506,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22598.72,100,MS DRG,18078.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8711.94,10363,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27955.63,100,MS DRG,22364.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8712.94,10364,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20055.07,100,MS DRG,16044.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8713.94,10365,
ARTHROSCOPY,509,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25741.37,100,MS DRG,20593.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8714.94,10366,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39178.17,100,MS DRG,31342.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8715.94,10367,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28236.22,100,MS DRG,22588.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8716.94,10368,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23924.83,100,MS DRG,19139.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8717.94,10369,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22678.02,100,MS DRG,18142.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8718.94,10370,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16748.94,100,MS DRG,13399.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8719.94,10371,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,42036.57,100,MS DRG,33629.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8720.94,10372,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28852.31,100,MS DRG,23081.85,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8721.94,10373,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22520.66,100,MS DRG,18016.53,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8722.94,10374,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,48033.97,100,MS DRG,38427.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8723.94,10375,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28366.75,100,MS DRG,22693.4,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8724.94,10376,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21794.76,100,MS DRG,17435.81,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8725.94,10377,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39868.68,100,MS DRG,31894.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8726.94,10378,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30028.37,100,MS DRG,24022.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8727.94,10379,
FRACTURES OF FEMUR WITH MCC,533,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22913.46,100,MS DRG,18330.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8728.94,10380,
FRACTURES OF FEMUR WITHOUT MCC,534,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14240.68,100,MS DRG,11392.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8729.94,10381,
FRACTURES OF HIP AND PELVIS WITH MCC,535,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20534.53,100,MS DRG,16427.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8730.94,10382,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14202.86,100,MS DRG,11362.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8731.94,10383,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15521.64,100,MS DRG,12417.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8732.94,10384,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12502.22,100,MS DRG,10001.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8733.94,10385,
OSTEOMYELITIS WITH MCC,539,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28982.84,100,MS DRG,23186.27,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8734.94,10386,
OSTEOMYELITIS WITH CC,540,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20097.77,100,MS DRG,16078.22,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8735.94,10387,
OSTEOMYELITIS WITHOUT CC/MCC,541,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14983.65,100,MS DRG,11986.92,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8736.94,10388,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27063.83,100,MS DRG,21651.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8737.94,10389,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17252.79,100,MS DRG,13802.23,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8738.94,10390,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13529.44,100,MS DRG,10823.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8739.94,10391,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35137.61,100,MS DRG,28110.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8740.94,10392,
CONNECTIVE TISSUE DISORDERS WITH CC,546,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18433.72,100,MS DRG,14746.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8741.94,10393,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13413.54,100,MS DRG,10730.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8742.94,10394,
SEPTIC ARTHRITIS WITH MCC,548,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28887.68,100,MS DRG,23110.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8743.94,10395,
SEPTIC ARTHRITIS WITH CC,549,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19012.01,100,MS DRG,15209.61,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8744.94,10396,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14827.49,100,MS DRG,11861.99,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8745.94,10397,
MEDICAL BACK PROBLEMS WITH MCC,551,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25127.73,100,MS DRG,20102.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8746.94,10398,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16068.2,100,MS DRG,12854.56,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8747.94,10399,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20242.95,100,MS DRG,16194.36,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8748.94,10400,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14491.99,100,MS DRG,11593.59,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8749.94,10401,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20738.25,100,MS DRG,16590.6,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8750.94,10402,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14271.19,100,MS DRG,11416.95,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8751.94,10403,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23216.03,100,MS DRG,18572.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8752.94,10404,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14848.22,100,MS DRG,11878.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8753.94,10405,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26956.47,100,MS DRG,21565.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8754.94,10406,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18201.94,100,MS DRG,14561.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8755.94,10407,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14284.6,100,MS DRG,11427.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8756.94,10408,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22164.41,100,MS DRG,17731.53,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8757.94,10409,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15214.21,100,MS DRG,12171.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8758.94,10410,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23453.93,100,MS DRG,18763.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8759.94,10411,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16750.16,100,MS DRG,13400.13,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8760.94,10412,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13436.72,100,MS DRG,10749.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8761.94,10413,
SKIN DEBRIDEMENT WITH MCC,570,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,41033.76,100,MS DRG,32827.01,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8762.94,10414,
SKIN DEBRIDEMENT WITH CC,571,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24736.12,100,MS DRG,19788.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8763.94,10415,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18247.08,100,MS DRG,14597.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8764.94,10416,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,79438.54,100,MS DRG,63550.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8765.94,10417,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46580.98,100,MS DRG,37264.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8766.94,10418,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28669.32,100,MS DRG,22935.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8767.94,10419,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,70131.36,100,MS DRG,56105.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8768.94,10420,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36795.56,100,MS DRG,29436.45,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8769.94,10421,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24932.54,100,MS DRG,19946.03,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8770.94,10422,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,44073.93,100,MS DRG,35259.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8771.94,10423,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25940.23,100,MS DRG,20752.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8772.94,10424,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21867.96,100,MS DRG,17494.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8773.94,10425,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25674.28,100,MS DRG,20539.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8774.94,10426,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24350.61,100,MS DRG,19480.49,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8775.94,10427,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29287.83,100,MS DRG,23430.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8776.94,10428,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28527.79,100,MS DRG,22822.23,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8777.94,10429,
SKIN ULCERS WITH MCC,592,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29396.42,100,MS DRG,23517.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8778.94,10430,
SKIN ULCERS WITH CC,593,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19226.72,100,MS DRG,15381.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8779.94,10431,
SKIN ULCERS WITHOUT CC/MCC,594,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14664.01,100,MS DRG,11731.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8780.94,10432,
MAJOR SKIN DISORDERS WITH MCC,595,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30113.76,100,MS DRG,24091.01,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8781.94,10433,
MAJOR SKIN DISORDERS WITHOUT MCC,596,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17499.23,100,MS DRG,13999.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8782.94,10434,
MALIGNANT BREAST DISORDERS WITH MCC,597,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25741.37,100,MS DRG,20593.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8783.94,10435,
MALIGNANT BREAST DISORDERS WITH CC,598,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17472.39,100,MS DRG,13977.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8784.94,10436,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14739.64,100,MS DRG,11791.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8785.94,10437,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15980.36,100,MS DRG,12784.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8786.94,10438,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11623.83,100,MS DRG,9299.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8787.94,10439,
CELLULITIS WITH MCC,602,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22233.95,100,MS DRG,17787.16,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8788.94,10440,
CELLULITIS WITHOUT MCC,603,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15055.62,100,MS DRG,12044.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8789.94,10441,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22435.25,100,MS DRG,17948.2,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8790.94,10442,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15578.99,100,MS DRG,12463.19,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8791.94,10443,
MINOR SKIN DISORDERS WITH MCC,606,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23955.33,100,MS DRG,19164.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8792.94,10444,
MINOR SKIN DISORDERS WITHOUT MCC,607,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14853.11,100,MS DRG,11882.49,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8793.94,10445,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32113.29,100,MS DRG,25690.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8794.94,10446,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21792.32,100,MS DRG,17433.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8795.94,10447,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,51462.09,100,MS DRG,41169.67,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8796.94,10448,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27875.12,100,MS DRG,22300.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8797.94,10449,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19499.99,100,MS DRG,15599.99,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8798.94,10450,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37572.69,100,MS DRG,30058.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8799.94,10451,
O.R. PROCEDURES FOR OBESITY WITH CC,620,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23793.07,100,MS DRG,19034.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8800.94,10452,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22143.68,100,MS DRG,17714.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8801.94,10453,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,49961.51,100,MS DRG,39969.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8802.94,10454,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27645.76,100,MS DRG,22116.61,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8803.94,10455,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16547.65,100,MS DRG,13238.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8804.94,10456,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39287.97,100,MS DRG,31430.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8805.94,10457,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22723.15,100,MS DRG,18178.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8806.94,10458,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19765.93,100,MS DRG,15812.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8807.94,10459,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,52446.61,100,MS DRG,41957.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8808.94,10460,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31748.53,100,MS DRG,25398.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8809.94,10461,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21405.58,100,MS DRG,17124.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8810.94,10462,
DIABETES WITH MCC,637,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22076.58,100,MS DRG,17661.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8811.94,10463,
DIABETES WITH CC,638,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15499.69,100,MS DRG,12399.75,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8812.94,10464,
DIABETES WITHOUT CC/MCC,639,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11954.45,100,MS DRG,9563.56,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8813.94,10465,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20511.35,100,MS DRG,16409.08,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8814.94,10466,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13842.96,100,MS DRG,11074.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8815.94,10467,
INBORN AND OTHER DISORDERS OF METABOLISM,642,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19451.19,100,MS DRG,15560.95,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8816.94,10468,
ENDOCRINE DISORDERS WITH MCC,643,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24528.72,100,MS DRG,19622.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8817.94,10469,
ENDOCRINE DISORDERS WITH CC,644,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16917.3,100,MS DRG,13533.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8818.94,10470,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13810.03,100,MS DRG,11048.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8819.94,10471,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,60517.96,100,MS DRG,48414.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8820.94,10472,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46673.69,100,MS DRG,37338.95,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8821.94,10473,
KIDNEY TRANSPLANT,652,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,41780.38,100,MS DRG,33424.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8822.94,10474,
MAJOR BLADDER PROCEDURES WITH MCC,653,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,72318.76,100,MS DRG,57855.01,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8823.94,10475,
MAJOR BLADDER PROCEDURES WITH CC,654,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,38738.98,100,MS DRG,30991.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8824.94,10476,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29652.62,100,MS DRG,23722.1,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8825.94,10477,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,44056.85,100,MS DRG,35245.48,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8826.94,10478,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26612.42,100,MS DRG,21289.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8827.94,10479,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22658.5,100,MS DRG,18126.8,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8828.94,10480,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35837.88,100,MS DRG,28670.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8829.94,10481,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20657.74,100,MS DRG,16526.19,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8830.94,10482,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16834.34,100,MS DRG,13467.47,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8831.94,10483,
MINOR BLADDER PROCEDURES WITH MCC,662,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,42368.4,100,MS DRG,33894.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8832.94,10484,
MINOR BLADDER PROCEDURES WITH CC,663,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22943.98,100,MS DRG,18355.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8833.94,10485,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17483.37,100,MS DRG,13986.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8834.94,10486,
PROSTATECTOMY WITH MCC,665,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,46199.12,100,MS DRG,36959.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8835.94,10487,
PROSTATECTOMY WITH CC,666,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24406.71,100,MS DRG,19525.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8836.94,10488,
PROSTATECTOMY WITHOUT CC/MCC,667,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16848.98,100,MS DRG,13479.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8837.94,10489,
TRANSURETHRAL PROCEDURES WITH MCC,668,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39888.19,100,MS DRG,31910.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8838.94,10490,
TRANSURETHRAL PROCEDURES WITH CC,669,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23189.18,100,MS DRG,18551.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8839.94,10491,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15969.38,100,MS DRG,12775.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8840.94,10492,
URETHRAL PROCEDURES WITH CC/MCC,671,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25338.78,100,MS DRG,20271.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8841.94,10493,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17661.49,100,MS DRG,14129.19,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8842.94,10494,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,55422.13,100,MS DRG,44337.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8843.94,10495,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32471.96,100,MS DRG,25977.57,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8844.94,10496,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23406.34,100,MS DRG,18725.07,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8845.94,10497,
RENAL FAILURE WITH MCC,682,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22632.88,100,MS DRG,18106.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8846.94,10498,
RENAL FAILURE WITH CC,683,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15154.45,100,MS DRG,12123.56,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8847.94,10499,
RENAL FAILURE WITHOUT CC/MCC,684,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11720.22,100,MS DRG,9376.18,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8848.94,10500,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27315.14,100,MS DRG,21852.11,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8849.94,10501,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17152.75,100,MS DRG,13722.2,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8850.94,10502,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13145.15,100,MS DRG,10516.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8851.94,10503,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18587.45,100,MS DRG,14869.96,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8852.94,10504,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14101.61,100,MS DRG,11281.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8853.94,10505,
URINARY STONES WITH MCC,693,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22248.58,100,MS DRG,17798.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8854.94,10506,
URINARY STONES WITHOUT MCC,694,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13842.96,100,MS DRG,11074.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8855.94,10507,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18068.96,100,MS DRG,14455.17,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8856.94,10508,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12749.87,100,MS DRG,10199.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8857.94,10509,
URETHRAL STRICTURE,697,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16531.79,100,MS DRG,13225.43,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8858.94,10510,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24816.64,100,MS DRG,19853.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8859.94,10511,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16752.61,100,MS DRG,13402.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8860.94,10512,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12779.15,100,MS DRG,10223.32,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8861.94,10513,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27984.91,100,MS DRG,22387.93,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8862.94,10514,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22396.2,100,MS DRG,17916.96,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8863.94,10515,
PENIS PROCEDURES WITH CC/MCC,709,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31724.12,100,MS DRG,25379.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8864.94,10516,
PENIS PROCEDURES WITHOUT CC/MCC,710,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22626.79,100,MS DRG,18101.43,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8865.94,10517,
TESTES PROCEDURES WITH CC/MCC,711,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27618.92,100,MS DRG,22095.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8866.94,10518,
TESTES PROCEDURES WITHOUT CC/MCC,712,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17358.93,100,MS DRG,13887.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8867.94,10519,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21950.92,100,MS DRG,17560.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8868.94,10520,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15774.18,100,MS DRG,12619.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8869.94,10521,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31860.77,100,MS DRG,25488.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8870.94,10522,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21625.19,100,MS DRG,17300.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8871.94,10523,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26946.71,100,MS DRG,21557.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8872.94,10524,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19338.95,100,MS DRG,15471.16,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8873.94,10525,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25402.22,100,MS DRG,20321.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8874.94,10526,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18009.19,100,MS DRG,14407.35,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8875.94,10527,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13198.82,100,MS DRG,10559.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8876.94,10528,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19713.48,100,MS DRG,15770.78,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8877.94,10529,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13391.57,100,MS DRG,10713.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8878.94,10530,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22236.4,100,MS DRG,17789.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8879.94,10531,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14278.51,100,MS DRG,11422.81,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8880.94,10532,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17740.79,100,MS DRG,14192.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8881.94,10533,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11714.11,100,MS DRG,9371.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8882.94,10534,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29963.71,100,MS DRG,23970.97,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8883.94,10535,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19119.36,100,MS DRG,15295.49,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8884.94,10536,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,52347.79,100,MS DRG,41878.23,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8885.94,10537,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28690.05,100,MS DRG,22952.04,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8886.94,10538,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22815.87,100,MS DRG,18252.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8887.94,10539,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,52876.05,100,MS DRG,42300.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8888.94,10540,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26492.88,100,MS DRG,21194.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8889.94,10541,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21067.65,100,MS DRG,16854.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8890.94,10542,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26595.36,100,MS DRG,21276.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8891.94,10543,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18933.93,100,MS DRG,15147.14,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8892.94,10544,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28148.39,100,MS DRG,22518.71,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8893.94,10545,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16812.39,100,MS DRG,13449.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8894.94,10546,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24739.78,100,MS DRG,19791.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8895.94,10547,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15963.28,100,MS DRG,12770.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8896.94,10548,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20929.79,100,MS DRG,16743.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8897.94,10549,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35890.34,100,MS DRG,28712.27,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8898.94,10550,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20041.65,100,MS DRG,16033.32,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8899.94,10551,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26383.08,100,MS DRG,21106.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8900.94,10552,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17853.02,100,MS DRG,14282.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8901.94,10553,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15960.85,100,MS DRG,12768.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8902.94,10554,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21576.39,100,MS DRG,17261.11,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8903.94,10555,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16745.3,100,MS DRG,13396.24,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8904.94,10556,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12117.93,100,MS DRG,9694.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8905.94,10557,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16334.15,100,MS DRG,13067.32,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8906.94,10558,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12043.5,100,MS DRG,9634.8,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8907.94,10559,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17684.67,100,MS DRG,14147.74,case rate,100% of cms ipps rate,2000,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8908.94,10560,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21261.63,100,MS DRG,17009.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8909.94,10561,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17437.01,100,MS DRG,13949.61,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8910.94,10562,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13014.6,100,MS DRG,10411.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8911.94,10563,
ABORTION WITHOUT D&C,779,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15714.4,100,MS DRG,12571.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8912.94,10564,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26783.23,100,MS DRG,21426.58,case rate,100% of cms ipps rate,2600,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8913.94,10565,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17522.41,100,MS DRG,14017.93,case rate,100% of cms ipps rate,2600,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8914.94,10566,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14966.56,100,MS DRG,11973.25,case rate,100% of cms ipps rate,2600,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8915.94,10567,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24023.65,100,MS DRG,19218.92,case rate,100% of cms ipps rate,2600,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8916.94,10568,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17263.78,100,MS DRG,13811.02,case rate,100% of cms ipps rate,2600,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8917.94,10569,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15347.19,100,MS DRG,12277.75,case rate,100% of cms ipps rate,2600,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8918.94,10570,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26301.35,100,MS DRG,21041.08,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8919.94,10571,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,76835.11,100,MS DRG,61468.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8920.94,10572,
PREMATURITY WITH MAJOR PROBLEMS,791,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,53839.82,100,MS DRG,43071.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8921.94,10573,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,34195.79,100,MS DRG,27356.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8922.94,10574,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,55189.11,100,MS DRG,44151.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8923.94,10575,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22319.35,100,MS DRG,17855.48,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8924.94,10576,
NORMAL NEWBORN,795,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,6747.6,100,MS DRG,5398.08,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8925.94,10577,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19884.28,100,MS DRG,15907.42,case rate,100% of cms ipps rate,2000,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8926.94,10578,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16121.88,100,MS DRG,12897.5,case rate,100% of cms ipps rate,2000,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8927.94,10579,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16121.88,100,MS DRG,12897.5,case rate,100% of cms ipps rate,2000,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8928.94,10580,
SPLENIC PROCEDURES WITH MCC,799,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,62317.42,100,MS DRG,49853.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8929.94,10581,
SPLENIC PROCEDURES WITH CC,800,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,39857.69,100,MS DRG,31886.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8930.94,10582,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24338.4,100,MS DRG,19470.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8931.94,10583,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,48043.72,100,MS DRG,38434.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8932.94,10584,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26025.63,100,MS DRG,20820.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8933.94,10585,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17798.12,100,MS DRG,14238.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8934.94,10586,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16485.44,100,MS DRG,13188.35,case rate,100% of cms ipps rate,2000,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8935.94,10587,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13137.83,100,MS DRG,10510.26,case rate,100% of cms ipps rate,2000,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8936.94,10588,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12084.99,100,MS DRG,9667.99,case rate,100% of cms ipps rate,2000,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8937.94,10589,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,32251.16,100,MS DRG,25800.93,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8938.94,10590,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19419.47,100,MS DRG,15535.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8939.94,10591,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15921.8,100,MS DRG,12737.44,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8940.94,10592,
RED BLOOD CELL DISORDERS WITH MCC,811,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21473.9,100,MS DRG,17179.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8941.94,10593,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15569.23,100,MS DRG,12455.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8942.94,10594,
COAGULATION DISORDERS,813,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23195.3,100,MS DRG,18556.24,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8943.94,10595,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29813.65,100,MS DRG,23850.92,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8944.94,10596,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16706.25,100,MS DRG,13365,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8945.94,10597,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12354.6,100,MS DRG,9883.68,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8946.94,10598,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35237.65,100,MS DRG,28190.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8947.94,10599,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20023.36,100,MS DRG,16018.69,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8948.94,10600,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14271.19,100,MS DRG,11416.95,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8949.94,10601,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,75340.65,100,MS DRG,60272.52,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8950.94,10602,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31544.8,100,MS DRG,25235.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8951.94,10603,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18262.93,100,MS DRG,14610.34,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8952.94,10604,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,61398.78,100,MS DRG,49119.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8953.94,10605,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31142.2,100,MS DRG,24913.76,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8954.94,10606,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19325.54,100,MS DRG,15460.43,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8955.94,10607,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,62569.95,100,MS DRG,50055.96,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8956.94,10608,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,33100.26,100,MS DRG,26480.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8957.94,10609,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23865.06,100,MS DRG,19092.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8958.94,10610,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,41931.66,100,MS DRG,33545.33,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8959.94,10611,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22152.21,100,MS DRG,17721.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8960.94,10612,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18352,100,MS DRG,14681.6,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8961.94,10613,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13428.18,100,MS DRG,10742.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8962.94,10614,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,10651.51,100,MS DRG,8521.21,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8963.94,10615,
ACUTE LEUKEMIA WITH MCC,834,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,71741.72,100,MS DRG,57393.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8964.94,10616,
ACUTE LEUKEMIA WITH CC,835,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30367.52,100,MS DRG,24294.02,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8965.94,10617,
ACUTE LEUKEMIA WITHOUT CC/MCC,836,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19812.31,100,MS DRG,15849.85,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8966.94,10618,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,65396.63,100,MS DRG,52317.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8967.94,10619,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,29053.61,100,MS DRG,23242.89,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8968.94,10620,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21028.62,100,MS DRG,16822.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8969.94,10621,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,43215.07,100,MS DRG,34572.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8970.94,10622,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,23439.29,100,MS DRG,18751.43,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8971.94,10623,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17143,100,MS DRG,13714.4,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8972.94,10624,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27407.86,100,MS DRG,21926.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8973.94,10625,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18891.21,100,MS DRG,15112.97,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8974.94,10626,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14518.83,100,MS DRG,11615.06,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8975.94,10627,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,35465.8,100,MS DRG,28372.64,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8976.94,10628,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19812.31,100,MS DRG,15849.85,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8977.94,10629,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14300.46,100,MS DRG,11440.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8978.94,10630,
RADIOTHERAPY,849,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36896.82,100,MS DRG,29517.46,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8979.94,10631,
ACUTE LEUKEMIA WITH OTHER PROCEDURES,850,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,116692.88,100,MS DRG,93354.3,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8980.94,10632,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,65324.66,100,MS DRG,52259.73,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8981.94,10633,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28686.41,100,MS DRG,22949.13,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8982.94,10634,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24141.99,100,MS DRG,19313.59,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8983.94,10635,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,59350.45,100,MS DRG,47480.36,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8984.94,10636,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30892.11,100,MS DRG,24713.69,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8985.94,10637,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20028.24,100,MS DRG,16022.59,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8986.94,10638,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26741.76,100,MS DRG,21393.41,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8987.94,10639,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16508.6,100,MS DRG,13206.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8988.94,10640,
FEVER AND INFLAMMATORY CONDITIONS,864,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15265.46,100,MS DRG,12212.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8989.94,10641,
VIRAL ILLNESS WITH MCC,865,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22315.68,100,MS DRG,17852.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8990.94,10642,
VIRAL ILLNESS WITHOUT MCC,866,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15104.43,100,MS DRG,12083.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8991.94,10643,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30470.01,100,MS DRG,24376.01,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8992.94,10644,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17121.04,100,MS DRG,13696.83,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8993.94,10645,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,13089.02,100,MS DRG,10471.22,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8994.94,10646,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,89177.59,100,MS DRG,71342.07,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8995.94,10647,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28247.2,100,MS DRG,22597.76,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8996.94,10648,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16888.03,100,MS DRG,13510.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8997.94,10649,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,52250.19,100,MS DRG,41800.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8998.94,10650,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16004.76,100,MS DRG,12803.81,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,8999.94,10651,
DEPRESSIVE NEUROSES,881,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15461.88,100,MS DRG,12369.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9000.94,10652,
NEUROSES EXCEPT DEPRESSIVE,882,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16046.25,100,MS DRG,12837,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9001.94,10653,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26927.19,100,MS DRG,21541.75,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9002.94,10654,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24686.1,100,MS DRG,19748.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9003.94,10655,
PSYCHOSES,885,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21506.84,100,MS DRG,17205.47,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9004.94,10656,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26226.93,100,MS DRG,20981.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9005.94,10657,
OTHER MENTAL DISORDER DIAGNOSES,887,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18820.47,100,MS DRG,15056.38,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9006.94,10658,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11923.95,100,MS DRG,9539.16,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9007.94,10659,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21974.09,100,MS DRG,17579.27,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9008.94,10660,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26035.39,100,MS DRG,20828.31,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9009.94,10661,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15072.7,100,MS DRG,12058.16,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9010.94,10662,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,58361.05,100,MS DRG,46688.84,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9011.94,10663,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,27460.32,100,MS DRG,21968.26,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9012.94,10664,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19182.79,100,MS DRG,15346.23,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9013.94,10665,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,51414.52,100,MS DRG,41131.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9014.94,10666,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24417.71,100,MS DRG,19534.17,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9015.94,10667,
HAND PROCEDURES FOR INJURIES,906,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30936.03,100,MS DRG,24748.82,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9016.94,10668,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,52910.2,100,MS DRG,42328.16,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9017.94,10669,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28918.18,100,MS DRG,23134.54,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9018.94,10670,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,19783.02,100,MS DRG,15826.42,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9019.94,10671,
TRAUMATIC INJURY WITH MCC,913,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24052.94,100,MS DRG,19242.35,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9020.94,10672,
TRAUMATIC INJURY WITHOUT MCC,914,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15489.93,100,MS DRG,12391.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9021.94,10673,
ALLERGIC REACTIONS WITH MCC,915,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25512.02,100,MS DRG,20409.62,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9022.94,10674,
ALLERGIC REACTIONS WITHOUT MCC,916,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12411.94,100,MS DRG,9929.55,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9023.94,10675,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24314,100,MS DRG,19451.2,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9024.94,10676,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15101.98,100,MS DRG,12081.58,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9025.94,10677,
COMPLICATIONS OF TREATMENT WITH MCC,919,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,26557.54,100,MS DRG,21246.03,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9026.94,10678,
COMPLICATIONS OF TREATMENT WITH CC,920,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16703.81,100,MS DRG,13363.05,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9027.94,10679,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,12699.85,100,MS DRG,10159.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9028.94,10680,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24920.34,100,MS DRG,19936.27,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9029.94,10681,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16752.61,100,MS DRG,13402.09,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9030.94,10682,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,293722.11,100,MS DRG,234977.69,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9031.94,10683,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,85790.94,100,MS DRG,68632.75,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9032.94,10684,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,43110.16,100,MS DRG,34488.13,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9033.94,10685,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,57097.15,100,MS DRG,45677.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9034.94,10686,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30488.29,100,MS DRG,24390.63,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9035.94,10687,
NON-EXTENSIVE BURNS,935,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,31105.6,100,MS DRG,24884.48,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9036.94,10688,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,43032.07,100,MS DRG,34425.66,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9037.94,10689,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,30068.62,100,MS DRG,24054.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9038.94,10690,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,28152.05,100,MS DRG,22521.64,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9039.94,10691,
REHABILITATION WITH CC/MCC,945,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22933,100,MS DRG,18346.4,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9040.94,10692,
REHABILITATION WITHOUT CC/MCC,946,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17931.1,100,MS DRG,14344.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9041.94,10693,
SIGNS AND SYMPTOMS WITH MCC,947,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,20001.4,100,MS DRG,16001.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9042.94,10694,
SIGNS AND SYMPTOMS WITHOUT MCC,948,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,14002.79,100,MS DRG,11202.23,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9043.94,10695,
AFTERCARE WITH CC/MCC,949,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,17473.62,100,MS DRG,13978.9,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9044.94,10696,
AFTERCARE WITHOUT CC/MCC,950,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11460.36,100,MS DRG,9168.29,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9045.94,10697,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,11227.35,100,MS DRG,8981.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9046.94,10698,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,87613.59,100,MS DRG,70090.87,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9047.94,10699,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,50942.39,100,MS DRG,40753.91,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9048.94,10700,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,95371.4,100,MS DRG,76297.12,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9049.94,10701,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,54448.59,100,MS DRG,43558.87,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9050.94,10702,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36564.98,100,MS DRG,29251.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9051.94,10703,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,37453.12,100,MS DRG,29962.5,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9052.94,10704,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,22610.93,100,MS DRG,18088.74,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9053.94,10705,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,15443.58,100,MS DRG,12354.86,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9054.94,10706,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,81464.92,100,MS DRG,65171.94,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9055.94,10707,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,36679.66,100,MS DRG,29343.73,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9056.94,10708,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,40740.96,100,MS DRG,32592.77,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9057.94,10709,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21650.8,100,MS DRG,17320.64,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9058.94,10710,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,16546.44,100,MS DRG,13237.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9059.94,10711,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,21900.9,100,MS DRG,17520.72,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9060.94,10712,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,62306.44,100,MS DRG,49845.15,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9061.94,10713,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,34178.72,100,MS DRG,27342.98,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9062.94,10714,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,24661.71,100,MS DRG,19729.37,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9063.94,10715,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,47042.12,100,MS DRG,37633.7,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9064.94,10716,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,25244.85,100,MS DRG,20195.88,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9065.94,10717,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,18406.89,100,MS DRG,14725.51,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9066.94,10718,
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,998,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,4310.09,100,MS DRG,3448.07,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9067.94,10719,
UNGROUPABLE,999,CDM,100,RC,,,INPATIENT,,,,,,1300,100,,,per diem,Pays based on per day rate,,,,,other,Not separately reimbursable,,,,,,,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,2737.25,100,,,per diem,Pays based on per day rate,4310.09,100,MS DRG,3448.07,case rate,100% of cms ipps rate,2400,100,,,per diem,Pays based on per day rate,2737.25,100,,,per diem,Pays based on per day rate,9068.94,10720,